Crush Step 3
CCS: The Ultimate
USMLE Step 3
CCS Review
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Crush Step 3
CCS: The Ultimate
USMLE Step 3
CCS Review
MAYUR K. MOVALIA, MD
Internship, Internal Medicine
University of Hawaii
Honolulu, Hawaii
Hematopathologist
Dahl-Chase Pathology Associates
Medical Director, Flow Cytometry Laboratory
Dahl-Chase Diagnostic Services
Medical Director, Affiliated Laboratories
Eastern Maine Medical Center
Bangor, Maine
Medical Director, Cancer Care of Maine Laboratory
Brewer, Maine
Medical Director, Mount Desert Island Hospital Laboratory
Bar Harbor, Maine
Faculty and Instructor
University of Maine
Orono, Maine
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
CRUSH STEP 3 CCS: THE ULTIMATE USMLE
STEP 3 CCS REVIEW
ISBN: 978-1-4557-2374-4
Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using
such information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Movalia, Mayur.
Crush step 3 CCS: the ultimate USMLE step 3 CCS review / Mayur K. Movalia. -- 1st ed.
p. ; cm.
ISBN 978-1-4557-2374-4 (pbk.)
I. Title.
[DNLM: 1. Clinical Medicine--Examination Questions. WB 18.2]
616.0076--dc23
2012036370
Senior Content Strategist: James Merritt
Content Developmental Specialist: Christine Abshire
Publishing Services Manager: Hemamalini Rajendrababu
Project Manager: Kamatchi Madhavan
Designer: Louis Forgione
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wonderful wife, Neela, and to my kids, Raina, Ryan, and Renee, for their laughter, encouragement,
and unconditional support.
Mayur K. Movalia
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P H Y S I C I A N
R E V I E W
B O A R D
Each of the following reviewers scored above the 90th percentile on USMLE Step 3 with most
scoring in the 99th percentile.
The author and publisher express sincere gratitude to these physicians for their many helpful
comments, suggestions, and recommendations for improving the text that appears in this book.
Whitney K. Bryant, MD, MPH
Simulation and Medical Education Fellow
Assistant Professor of Emergency Medicine
University of Cincinnati
Cincinnati, Ohio
Yewlin E. Chee, MD
Resident in Ophthalmology
Massachusetts Eye and Ear Infirmary
Harvard Medical School
Boston, Massachusetts
Linda Hall, MD
Family Physician
Beartooth Billings Clinic
Red Lodge, Montana
Capt. Jason M. Johnson, MD, USAFR
Clinical Fellow in Neuroradiology
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts
Jessica J. Kraeft, MD
Radiology Resident
Mount Auburn Hospital
Harvard Medical School
Cambridge, Massachusetts
Joseph T. Nezgoda, MD, MBA
Ophthalmology Resident
University Hospitals Case Medical Center
Cleveland, Ohio
vii
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PREFACE
The Computer-based Case Simulation (CCS) portion of USMLE Step 3 comprises 12 interactive cases over 4 hours designed to evaluate your approach to patient management. This
book was created to provide a high-yield, rapid, comprehensive review for the CCS cases.
Studying for the CCS portion of Step 3 presents some unique challenges from studying for the multiple-choice question (MCQ) portion. Most important, understanding the
USMLE CCS Primum® software is essential to performing well. As soon as you decide
to take Step 3, download the Primum® CCS software from the official www.usmle.org
website under “Practice Materials.” An in-depth review of the software is provided in
this book. Practice the six cases that are supplied by the USMLE and get a good feel for
how to place orders, what orders are available, how to manage the clock, how to transfer
patients, and all the various features of the software. Practice the sample cases multiple
times and see how the software responds to performing correct actions and performing incorrect actions. Once you are comfortable with the software, you can really start
using this book and studying for the exam.
This book incorporates the concept of bidirectional learning, which emphasizes
relationship building and associative memories. Each CCS case is presented on two
pages. The first page shows a brief sample case presentation with relevant information
presented in a format similar to the actual exam. The second page presents a review of
the disease entity with a focus on diagnosis, management, and important points in the
CCS matrix. Each case can be studied beginning from the first page or the second page.
How to Use This Book:
As a self-test
n To use as a self-test, begin with the first page of a case and read through the case
presentation. In most cases, the diagnosis should be suspected from the information provided. On a blank sheet of paper or in your head, create a sequence
for how you would manage the patient. Compare your management with what
is presented on the second page.
n As a review book
n To use as a review book, start backward with the second page of a case. At the top,
the final diagnosis is listed. Beginning with the final diagnosis, try to recall important points in the diagnosis and management. In addition, create a CCS matrix with
the six domains and compare your results with those listed in the table provided.
n As a practice exam
n To use as a practice exam, open a CCS case in the USMLE Primum® software
(Case 1 begins in the emergency department and Case 2 begins in the office).
Begin with the first page of a case and read through the introduction. Using the
software, order the appropriate management (exam, labs, imaging, and treatment). Compare what you did in the software with the management recommended on the second page.
Preparing well for the CCS portion of Step 3 can have a dramatic impact on your overall
Step 3 score. If you learn the concepts, strategies, and cases in this book, you should
not just do well on the CCS cases, you should CRUSH them!
I wish you much success on your exam, residency, career, and future.
n
Mayur K. Movalia, MD
ix
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CONTENTS
SECTION
I Introduction 1
1
Primum® CCS Software
2
Tips and Strategies
3
Reference Sheet
4
USMLE Primum® CCS Cases
SECTION
2
8
10
12
II CCS Cases by Chief Complaint 27
5
Abdominal Pain
28
6
Fatigue
7
Chest Pain
8
Altered Mental Status
98
9
Pain in the Extremities
124
62
88
10
Cough
11
Trauma
12
Shortness of Breath
13
Back Pain
14
Diarrhea
15
Headache
16
Bruising
17
Routine Health Exam
18
Miscellaneous Internal Medicine Cases 234
19
Vaginal Bleeding
20
Vaginal Discharge
21
Miscellaneous Obstetrics/Gynecology Cases
22
Pediatric Fever
23
Miscellaneous Pediatric Cases 284
APPENDIX
138
154
160
180
192
204
216
224
246
256
264
276
CS Cases Listed by Case Number and Alphabetically
C
by Final Diagnosis 293
xi
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S E C T I O N
Introduction
I
C H A P T E R
1
Primum® CCS Software
To perform well on the Computer-based Case Simulations (CCS), it is important to have a
good understanding of the USMLE Primum® software. The best way to learn the software is
to download the Primum® software from the USMLE.org website and practice the sample
cases on it. Six CCS cases are provided by the USMLE for practice along with basic explanations. The following sections highlight important features of the software. Each year, the
Primum® software undergoes minor updates and modifications so it is important to download the most recent version. The following section is updated to the 2012–2013 Primum®
software.
Scoring
The USMLE does not publish exactly how each case is scored and how much of the overall Step 3
score the CCS portion accounts for; however, based on the time allocated to the CCS, it can be
estimated that about 25% to 30% of your overall Step 3 score is based on your performance on
the CCS cases.
Any action you perform may add to, subtract from, or have no effect on your score. Of the
thousands of orders and actions possible in the software, most will likely have no effect on your
score.
For each CCS case, there are multiple correct approaches that exist that will achieve a high
score. Although we have tried in this book to outline management of cases consistent with widely
accepted standards, there may be alternative approaches that are equally valid. Feel free to modify,
adjust, and alter any recommendations in this book to your own preferences and experience.
Real Time and Simulated Time
The CCS portion consists of 12 cases: a combination of 10- and 20-minute cases in real time. At
the beginning of each case, the Start Case screen will show you the allocated real time for each case.
n 10-minute case: 8 minutes of case time + 2 minutes for case-end orders
n 20-minute case: 18 minutes of case time + 2 minutes for case-end orders
The following are examples of 10- and 20-minute real-time cases from the six practice cases
on USMLE.org:
n 10-minute Cases:
n Case 1: Tension Pneumothorax
n Case 6: Eclampsia with Fetal Distress
n 20-minute Cases
n Case 2: Rheumatoid Arthritis
n Case 3: Ascending Aortic Dissection
n Case 4: Asthma
n Case 5: Diabetic Ketoacidosis with E. coli Sepsis
In general, the 10-minute cases will be those that require rapid management with less follow-up
required after definitive therapy.
1—PRIMUM® CCS SOFTWARE
3
Each case may last a few minutes to several months in simulated time. For patients who
present with chronic conditions, such as rheumatoid arthritis, follow-up over several weeks of
simulated time may be required.
For each case, the real and simulated times are displayed at the bottom left of the screen.
The Six CCS Domains
Each case is scored according to six domains: diagnosis, therapy, monitoring, timing, sequence,
and location. Every case in this book is analyzed according to those domains. For most cases,
the orders are split into “optimal” and “additional” orders. The optimal orders are those that
are most critical for management and likely to generate the highest points. The additional
orders are those that either may generate a smaller number of points or may have no effect on
your score but are often ordered. Some domains may not be important for each case. Each of
the six domains is explained below with examples from the six CCS practice cases from the
USMLE.org website.
1.Diagnosis: This can include physical examination, laboratory studies, imaging studies, or
procedures. In some cases, a limited physical exam is all you need to reach a diagnosis.
a.A patient who presents with tension pneumothorax in the emergency department (ED)
should be diagnosed based on history and a limited physical exam.
b.A patient who presents to the office with rheumatoid arthritis is diagnosed based on
history, physical exam, lab studies, synovial fluid studies, and imaging.
c.A patient who presents to the ED with ascending aortic dissection is diagnosed based
on history and exam with confirmation by imaging (chest CT or TEE)
d.A patient who presents to the ED with diabetic ketoacidosis is diagnosed based on history, exam, glucose measurement, ABG, and urinalysis.
2.Therapy: This can include medications, surgery, invasive procedures, consultation, counseling, or just simple reassurance. In some cases, canceling a medication that the patient was
previously on may be part of the therapy.
a.A patient with tension pneumothorax is managed with needle thoracostomy followed
by chest tube or surgical consult.
b.A patient with rheumatoid arthritis is managed with an NSAID or a corticosteroid, a
DMARD (such as methotrexate), and either exercise counseling or physical therapy
consult.
c.A patient with eclampsia is managed with IV magnesium sulfate, IV antihypertensive
medication, and fetal delivery either by C-section or consulting ob-gyn.
d.A patient with diabetic ketoacidosis and sepsis is managed with IV fluids, repletion of
electrolytes, IV antibiotics, and IV insulin.
3.Monitoring: This can include monitoring abnormal vital signs, physical exam findings,
laboratory studies, or imaging studies. In patients who have an abnormal exam finding,
you should make sure to check that the abnormal finding has resolved or improved after
therapy has been instituted.
a.A patient with tension pneumothorax should have blood pressure, heart rate, oxygen
saturation, and respiratory rate monitored until the condition has stabilized.
b.A patient with diabetic ketoacidosis and sepsis should have cardiovascular status monitored and should have glucose, electrolytes, and ABG monitored during
therapy.
c.A child who presents with asthma should have pulse oximetry and a repeat chest/lung
exam ordered after therapy to monitor respiratory status.
d.A pregnant patient who presents with eclampsia and fetal distress should have a blood
pressure monitor, cardiac monitor, fetal monitor, and monitoring of urine output.
4
I—INTRODUCTION
4.Timing: This can vary depending on the severity of each case, but it is important
to make sure to complete diagnosis and institute management within a reasonable
amount of simulated time. In general, patients who present acutely to the ED should
be managed within 1 to 2 hours, and patients in the office should be managed in several
hours to days.
a.A woman who presents to the ED with diabetic ketoacidosis and sepsis should be
diagnosed and have therapy instituted within 1 hour.
b.A child who presents to the office with shortness of breath from asthma should have
therapy instituted on the first visit within 12 hours of simulated time.
c.A pregnant woman who presents to the ED with eclampsia and fetal distress should be
managed within 1 hour.
d.A woman who presents to the ED with ascending aortic dissection should be managed
within 2 hours.
5.Sequence: Even though in many cases you may know the diagnosis from the history, it
is important to remember that each case should be managed in an appropriate sequence.
Do not skip too early to a treatment if the diagnosis has not been adequately confirmed
or if the patient has not been stabilized. Although you may order the correct treatment for the patient, you will lose points if your management is not in an appropriate
sequence.
a.A patient with ascending aortic dissection should be managed as follows. If you jump
too early to a diagnostic imaging study or surgical consult before you have stabilized the
blood pressure, you will not score the maximum points.
1)Monitoring (blood pressure monitor, cardiac monitor, pulse oximetry)
2)Targeted exam, including chest and heart
3)Initial diagnostic studies, labs, IV antihypertensive and opiate medications
4)Check blood pressure has improved
5)Chest imaging (such as chest CT) for confirmation of diagnosis
6)Advance to results of imaging confirming the aortic dissection
7)Open heart surgery or consult thoracic surgery
b.A patient with eclampsia and fetal distress should be managed as follows. If you order
fetal delivery too early before stabilizing the blood pressure, you will not score the
maximum points.
1)Monitoring (blood pressure monitor)
2)Exam
3)CBC, BMP, LFT, PT/PTT, urine output, IV magnesium, IV antihypertensive, fetal
monitor
4)Advance clock for lab results to rule out DIC and make sure seizures and blood
pressure have stabilized
5)Fetal delivery with cesarean section or ob-gyn consult after the patient is stabilized
6.Location: For many cases, location will not be a significant component of the score. Most
office patients can be managed as outpatients, and many ED patients can be managed in
the ED within the time frame of the case. However, for some cases, patients will require
a change in setting, such as an office patient who may need to be transferred to the ED or
inpatient unit for optimal diagnosis and management.
a.A patient with diabetic ketoacidosis and sepsis should be initially managed in the ED
and then changed to the ICU for monitoring.
b.A patient who presents to the office with unstable vital signs or requiring IV fluid, IV
medications, or a substantial workup and therapy will need to be transferred to the
inpatient unit.
5
1—PRIMUM® CCS SOFTWARE
CCS Primum® Software Management Options
INTERVAL HISTORY OR PHYSICAL EXAMINATION
n
n
n
or many cases, particularly in the office setting, management will begin with a physical
F
examination. A full physical exam takes 15 minutes. For unstable patients, try to limit the
initial exam to about 5 minutes or less. Each portion of the exam takes 1 minute except for
HEENT, genitalia, and rectal, which take 2 minutes each. (To illustrate how the CCS may
not match reality—a full neuro/psych exam takes 1 minute!)
Table 1.1 shows how a normal examination is presented on the CCS with some variations
for men, women, and children. It is important to be familiar with how a normal exam looks
on the CCS so it is easy to find abnormal results quickly, particularly if you have to read
through a long full physical exam.
The exam results will change after you do some intervention; therefore, remember to recheck
any abnormal exam findings after therapy is instituted.
TABLE 1.1 n Normal Physical Examination Findings on the CCS
Organ System
Time
Result
General
Skin
Breasts
1 min
1 min
1 min
Lymph nodes
HEENT/Neck
1 min
2 min
Chest/Lung
1 min
Heart/Cardiovascular
1 min
Abdomen
1 min
Genitalia
2 min
Rectal
2 min
Extremities/Spine
1 min
Neuro/Psych
1 min
Well developed, well nourished; no acute distress.
Normal turgor. No lesions. Hair and nails normal.
•Female: Nipples normal; no masses.
•Male: Normal.
No abnormal lymph nodes.
Normocephalic. Vision normal. Funduscopic examination
normal. Hearing normal. Ears including pinnae, external
auditory canals, and membranes normal. Nose and mouth
normal. Pharynx normal. Neck supple; no masses or bruits;
thyroid normal.
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion
or auscultation.
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous
distention. Blood pressure equal in both arms.
Bowel sounds normal; no bruits. No masses or tenderness.
Liver and spleen not palpable. No hernias.
•Female: Normal labia. No vaginal or cervical lesions. Uterus
not enlarged. No adnexal masses or tenderness.
•Male: Normal circumcised penis; normal scrotum; testes
without masses. No inguinal hernia.
•Child: Normal external genitalia.
Sphincter tone normal. No masses or abnormality. Stool brown;
no occult blood.
Extremities symmetric without deformity, cyanosis, or
clubbing. No edema. Peripheral pulses normal. No joint
deformity or warmth; full range of motion. Spine examination normal.
•Adult: Mental status normal. Findings on cranial nerve,
motor, and sensory examinations normal. Cerebellar function
normal. Deep tendon reflexes normal.
•Child: Alert; neurologic findings normal.
6
I—INTRODUCTION
WRITE ORDERS OR REVIEW CHART
The Write Orders function allows you to do the following:
n Enter orders.
n The software “clerk” recognizes a minimum of three letters.
n To order “Chest x-ray, PA/lateral,” you can enter “Che” and click order; however, the
software will pull up all of the orders beginning with “Che,” such as “check,” “chelate,”
“chem,” and “chest.” For an order like this, you will want to type either the whole
name or “chest x” to narrow the list.
n For many panels, it will save you time by ordering by abbreviations. Instead of entering
“Complete blood count,” “Basic metabolic profile,” “Liver function panel,” “arterial blood
gases,” and “electrocardiography,” it is quicker and easier to enter “CBC,” “BMP,” “LFT,”
“ABG,” and “ECG.” The software recognizes both the full names and abbreviations.
n A single order can be recognized in multiple ways.
n For medications, brand and generic names are recognized. You can order “Bactrim” or
“trimethoprim and sulfamethoxazole.” However, on the order sheet, only the generic
name will show up. For medications, you don’t have to enter the dose or worry about
tapering, although you have to enter the route of administration and whether it is one
time or continuous.
n An imaging study can be ordered by the body part, modality, or abbreviation. You
can order “Abdominal ultrasound,” “Ultrasound, abdomen,” or “US, abdomen.”
On the order sheet only “US, abdomen” will appear no matter how you choose to
order it.
n For lab tests, you can order by test name or specimen type. You can order “Sputum culture,” “Culture, bacterial, sputum,” or “Bacterial culture, sputum.” On the
order sheet, it will show up as “Bacterial culture, sputum” no matter how you
order it.
n Review orders.
n The order sheet includes any medications the patient is on at the start of the case as well
as any orders you enter during the case.
n For some cases, it will be important to review and cancel medications at the start of
the case. You can cancel orders by clicking on them.
n The order sheet will also list the report times for the various orders you enter. This can
affect how you advance the clock and if you want to add or change any orders as you
receive results.
n Review prior progress notes, vital signs, lab reports, imaging, other tests, and treatment
records.
n After an order has been entered and reported, it is removed from the order sheet and
placed into its appropriate category. This can be helpful to review any examination findings or diagnostic studies that were previously abnormal to make sure you remember to
repeat those to confirm improvement.
OBTAIN RESULTS OR SEE PATIENT LATER
The Obtain Results button is for advancing the clock. There are four options to advance the clock.
n On
n This allows you to follow up with a patient on a specific date. You can choose the day on
the calendar and enter a specific time. This is best for a stable office patient for whom
you might order a panel of tests that take 2 to 3 days for results. You can look at the order
sheet to see when results are reported and then reschedule the patient after the last result.
1—PRIMUM® CCS SOFTWARE
n
7
In
his allows you to follow up in a specific number of days, hours, or minutes. This is simiT
lar to the “On” button but is used more for an office or ED patient for whom a panel of
tests was ordered, and you may want to follow up in 30 minutes or 1 hour to see results of
a group of tests before deciding further management.
With next available result
n This is used more for unstable patients whose condition could change rapidly and you
would like to advance the clock relatively slowly with each result as it comes in.
Call/see me as needed
n This is generally used in the office setting after you have completed management. The
clock will advance on its own, and either the software will give you a patient update or the
case will end.
n
n
n
CHANGE LOCATION
The CCS Primum® software offers five locations:
n Emergency department
n Office
n Inpatient unit
n Intensive care unit
n Home
The majority of cases will start in either the office or ED setting. Occasionally, you may see a
patient in the inpatient unit who was already admitted for another condition.
In the office or ED setting, keep in mind criteria that would require changing location to the
inpatient unit or ICU rather than discharging or treating from home. Although there is a long list
of potential reasons for admission to the hospital, the following should serve as a general guide:
n Unstable vital signs: high fever, hypotension, hypertension, bradycardia, tachycardia
n Respiratory distress requiring oxygen
n Suspected child or elder abuse
n Failure to thrive
n Monitoring of vital signs, fetal heart rate, lab results, or imaging results required
n IV administration of fluids, medications, or antibiotics required
n Invasive or surgical procedure required
n Severe trauma causing fracture or acute injury
n Suicidal or psychotic patient with potential for harm to self or others
Patient Updates and Case End
Each case generally has one or two patient update screens to let you know how the patient is
responding to your management. If you get a patient update screen showing the patient is doing
worse, then reassess your diagnosis and management.
When a case ends, you are given 2 minutes to:
n Delete any orders you want canceled
n Add orders to be done now
n Add orders relevant to the patient’s “current” condition to be done in the future
At the end, you should review the orders you have placed, and if you remember something
that you missed previously, this is your last chance to try to score some points. Also, some orders
not appropriate in the time frame of the case but appropriate for the patient’s condition should
be placed. For example, if the case ends on a patient with an acute problem, such as diabetic ketoacidosis, and you want to counsel the patient regarding diabetes education or advise him or her to
stop smoking, that can be ordered at the end for a later time period.
C H A P T E R
2
Tips and Strategies
Below is a list of the top 10 tips and strategies for maximizing your score on the CCS.
1.Learn how to manage cases by chief complaint. Patients in real life and in the CCS cases
do not present with myocardial infarction, hypothyroidism, or tuberculosis; instead, they
­present with shortness of breath, fatigue, or cough. This is the main reason why this book
is ­organized by chief complaint. When a patient presents with abdominal pain, there are
20 or more possible diagnoses. Developing a strategy for how to handle CCS cases by chief
complaint is essential to doing well.
2.Create a reference sheet during the exam. It is very difficult to remember the numerous
orders and workups that go into each case. Often, during the rush of the actual exam, it is
difficult to remember common orders that would normally be second nature to you. For
example, it is not uncommon during the actual exam to forget to order an ECG or troponin
in a patient who presents in the emergency department with chest pain. For this reason, you
may find it useful to create a reference sheet to use during the exam. During the exam, you
are given two double-sided worksheets to use as you wish. Before beginning the CCS cases,
create your reference sheet on one of the worksheets. The reference sheet should contain
common orders for patients who present with common presenting symptoms, such as chest
pain, abdominal pain, shortness of breath, fatigue, altered mental status, cough, diarrhea,
bleeding, and vaginal discharge. Refer to Table 3.1 for a sample reference sheet. Practice
the cases in this book and on the CCS Primum® software with a reference sheet. Having
a reference sheet to help guide you through the cases will be a definite advantage during
the exam.
3.Learn to how to create a CCS matrix. CCS cases are graded according to six domains:
diagnosis, therapy, monitoring, timing, location, and sequencing. Each case in this book is
analyzed according to these domains. Having a good understanding of these domains for
each case will help in your management. Often, the diagnosis for a particular case will be
known early in the case, during the history or initial exam. However, much of your score is
determined after the diagnosis is known; therefore, it is important to have a good understanding of how each case may be graded according to each of the domains. For some test
takers, just having a mental awareness of these domains is sufficient. For others, it may be
helpful to use the blank worksheet provided during the exam and fill in each of the domains
as you work through the case and after you have figured out the diagnosis.
4.Practice cases on the USMLE Primum® software. Having a good understanding of the
software can have a dramatic impact on your score. Download the USMLE Primum®
CCS software from the usmle.org website and practice the six CCS case that are provided.
Compare what you did on the software with the recommendations in this book.
After you feel comfortable managing those cases, try to manage the cases in this book
using the ­Primum® software. Read the first page of a case and then go to the software and
pretend you were managing the patient on the actual software. Compare what you did with
what you see on the second page of the case.
5.Don’t narrow your differential diagnosis too soon. Although in many cases you can figure
out the diagnosis from just the initial history, be careful not to narrow your differential too
soon. For example, you may get a case of a patient who is a recent immigrant from Latin
2—TIPS AND STRATEGIES
9
America and presents with a cough. Although your first thought might be tuberculosis, the
patient in the case may actually have Hodgkin lymphoma or lupus pleuritis. Similarly, you
may get a case of a child who presents with bruising that you may first think is due to child
abuse but may actually be hemophilia.
6.Watch for CCS cases that have two diagnoses. In some cases, you may be able to figure
out the primary diagnosis relatively quickly and easily; however, the patient may have a
second important diagnosis that may go undetected if a complete workup is not performed.
For example, you may be presented with a patient who has diabetic ketoacidosis, but a
­complete workup shows the patient also has sepsis or an acute myocardial infarction.
In addition, it is not uncommon for female patients to present with one diagnosis but also
have an undiagnosed pregnancy. For example, you may be presented with a female patient
who has a UTI or a breast mass that turns out to be carcinoma, but checking a urine HCG
level also shows that the patient is pregnant, which may alter your therapy.
7.Don’t rely on consultants too much. Typically, consultants are not very helpful in the
CCS cases. Because the cases are designed to evaluate your management skills, often they
will tell you to manage the patient as you think appropriate. The only exception is when it
comes time to perform a surgical procedure. Because you should assume you are managing
the patient as a primary care physician, a surgical consult ordered at the appropriate time
will result in the consultant taking the patient for the procedure. Alternatively, you could
order the procedure yourself. If you encounter a situation in which you would normally
order a consult in real life, then you should probably go ahead and order it; just don’t expect
it to be very helpful.
8.Be careful about practicing online CCS cases. There are a variety of online options
for practicing CCS cases from third-party vendors. In some instances, practicing online
cases can help develop key skills, such as practicing lots of cases, remembering orders
from ­memory, and developing stamina under similar test-taking conditions. However,
online sources can never replicate the actual software and may get you used to options and
­strategies that do not apply to the real software. In most cases, you are probably better off
saving your money for a little celebration after you finish the exam.
9.Get plenty of rest the night before. The CCS cases are on the second day of testing, and
depending on how the first day went, you may be feeling stressed the night before. Try to
put any bad feelings from the first day out of your mind (I know, easier said than done) and
get adequate sleep the night before. The test is hard enough without having to fight fatigue,
headache, tiredness, or memory lapses from lack of sleep.
10.Have fun. Compared with the monotony of hundreds of multiple-choice questions, the
CCS cases are actually an enjoyable change during the exam. Some people even find them
fun. They are even more fun when you know what you’re doing. Hopefully, most of the
cases you encounter on the exam will come directly from this book. However, as long as you
are well prepared, it really shouldn’t matter which cases you see on the real exam.
C H A P T E R
3
Reference Sheet
On the following page, a sample reference sheet (Table 3.1) is provided to help with recall of common orders. There are roughly 2500 unique orders in the CCS software. Because many orders can
be placed with different terminology (e.g., “BMP” can also be ordered as “Basic metabolic panel”),
there are a total of 12,000 orders that are possible. The reference sheet attempts to narrow down
that list to the most important 100 to 150 orders for diagnosis.
During your preparation, use the reference sheet as you practice cases. Feel free to add, remove,
or change any orders on the reference sheet to your own preferences.
You may find it useful to try to memorize a reference sheet before the actual exam. On day 2
of the exam, recreate from memory the reference sheet on the blank worksheet provided to you
before you begin the CCS cases. The reference sheet will help guide you in your general workup
during the cases and ensure you don’t forget common orders.
11
3—REFERENCE SHEET
TABLE 3.1 n Common Orders: Sample Reference Sheet
Emergency Orders
Blood pressure monitor
Cardiac monitor
Pulse oximetry
Intravenous access
Normal saline, 0.9% NaCl
Suction airway
Airway, oral
Intubation, endotracheal
Mechanical ventilation
Common Orders
HCG, urine, qualitative
Counsel family/patient
Reassure patient
Advise patient, no smoking
Advise patient, exercise program
Advise patient, limit alcohol intake
Advise patient, medication
compliance
Advise patient, no illegal drug use
Advise patient, side effects of
medication
Advise patient, safe sex techniques
Abdominal Pain
FAST ultrasound
Abdominal ultrasound
Abdominal x-ray, acute series
Abdominal CT
Transvaginal ultrasound
Endoscopy
Barium enema
Urinalysis
Chest Pain
Chest x-ray, portable
ECG, 12-lead
Troponin I
D-dimer
Echocardiography
Chest CT
Fatigue
Fasting blood glucose
CBC
BMP
TSH
LFT
Urinalysis
Depression index
Colonoscopy
Endoscopy
Abdominal CT scan
Altered Mental Status
Fingerstick glucose
ECG, 12-lead
ABG
Head CT without contrast
Urinalysis
Urine culture
Blood culture
Ammonia
CBC
Vitamin B12, serum
Toxicology screen
Cough
Chest x-ray, PA/lateral
Sputum Gram stain
Sputum culture
Peak flow
Shortness of Breath
Chest x-ray
Troponin
CBC
ECG, 12-lead
BNP
Echocardiography
RSV antigen
D-dimer
Spiral chest CT
Bleeding or Bruising
CBC
PT/PTT
Bleeding time
Platelet antibody
Factor VIII activity
Factor IX activity
Ristocetin cofactor
Von Willebrand factor antigen
Consult, social services
Routine Health Screen
CBC
Fasting glucose
HCG, urine, qualitative
Lipid profile
TSH
Back Pain
Spine x-ray
Urinalysis
Prostate ultrasound
Vaginal Discharge
Vaginal pH
Wet mount
KOH prep
HCG, urine
HIV test, ELISA
HPV DNA probe, cervix
Chlamydia DNA probe, cervix
Gonorrhea DNA probe, cervix
Vaginal Bleeding
CBC
PT/PTT
Pap smear
HPV DNA probe, cervix
Endometrial biopsy
Colposcopy
Cervical biopsy
Pain in the Extremities
X-ray of extremity
Skeletal survey
D-dimer
Duplex scan, leg, venous
Rheumatoid factor
ANA
Arthrocentesis
Synovial fluid analysis
Fever
CBC
Urinalysis
Urine culture
Blood culture
CSF studies
Diarrhea
Colonoscopy
CT abdomen
P-ANCA
Stool ova & parasites
Stool Giardia antigen
Stool C. difficile toxin assay
Stool C & S
Sweat test
Cystic fibrosis DNA
Headache
ESR
Temporal artery biopsy
Depression index
C H A P T E R
4
USMLE Primum® CCS Cases
The cases in this chapter are similar to cases 1-6 on the 2012-2013 USMLE Primum® software,
which can be downloaded from the “Practice Materials” tab at USMLE.org.
Key Orders*
Order
CCS Terminology
Time to Results—
ED Setting
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Fingerstick glucose
Needle thoracentesis
Needle thoracostomy
Tube thoracostomy
Chest X-ray, portable
ECG, 12-lead
ABG
Urinalysis
CBC with differential
BMP
Echocardiography
Chest CT scan with contrast
Troponin I, serum
Urine culture
Blood culture
Pulse oximetry
Monitor, continuous blood pressure cuff
Monitor, cardiac
Glucose, blood, random, by Glucometer
Thoracentesis
Needle thoracostomy
Tube thoracostomy
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
Urinalysis
CBC with differential
Basic metabolic profile
Echocardiography
CT, chest, with contrast
Troponin I, serum
Bacterial culture, urine
Bacterial culture, blood
1 min
5 min
5 min
2 min
5 min
5 min
5 min
10 min
15 min
18 min
20 min
30 min
30 min
30 min
30 min
45 min
24 hr
30 hr
Order
CCS Terminology
Time to Results—
Office Setting
Peak flow
CBC with differential
PT/PTT
BMP
Wrist, X-ray
Knee, X-ray
ESR
Rheumatoid factor
ANA, serum
Cyclic citrullinated peptide antibody
Arthrocentesis
Synovial fluid, Gram stain
Synovial fluid, cell count
Synovial fluid, crystals
Synovial fluid, glucose
Synovial fluid analysis
Synovial fluid, culture
Peak flow
CBC with differential
PT/PTT
Basic metabolic profile
X-ray, wrist
X-ray, knee
Sedimentation rate, erythrocyte
Rheumatoid factor
Antibody, antinuclear, serum
Antibody, cyclic citrullinated peptide
Arthrocentesis
Gram stain, synovial fluid
Cell count, synovial fluid
Crystals, synovial fluid
Glucose, synovial fluid
Synovial fluid analysis
Bacterial culture, synovial fluid
5 min
30 min
30 min
30 min
30 min
30 min
90 min
24 hr
24 hr
48 hr
20 min
40 min
2 hr 20 min
2 hr 20 min
3 hr 20 min
5 hr 20 min
30 hr 20 min
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
4—USMLE PRIMUM® CCS CASES
13
Case #1
Location: Emergency Department
Chief Complaint: Chest pain, respiratory distress
Case introduction
Initial vital signs
Initial history
•A 62-year-old Latino man is brought to the emergency department for severe
chest pain and respiratory distress. He is in acute distress and holding the right
side of his chest.
•Pulse: 124 beats/min, Weak
•Respiratory rate: 32/min
•Blood pressure, systolic: 105 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient was at home resting when he developed severe, sudden right-sided
chest pain with marked acute respiratory distress. He rates the pain as 9 on
a 10-point scale. The pain increases with respiration. His wife states he has a
history of emphysema but has been generally healthy over the past few years.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Chest, Heart
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
91% (nl = 94–100)
Results (Pertinent Findings)
General
Well developed, appears in respiratory distress; moaning and holding the right
side of his chest.
Chest
Chest wall normal. Breath sounds absent on the right with hyperresonance to
percussion. Breath sounds normal on the left.
Heart
Tachycardia; Heart sounds faint. No murmurs. Bilateral central and peripheral
pulses weak. No jugular venous distention.
What is the suspected diagnosis, and what are the next steps in management?
14
I—INTRODUCTION
Case #1: Tension Pneumothorax
Keys to Diagnosis
n
n
n
To practice this case, go to USMLE Case #1 in the CCS Primum® software. Although these
patients can present spontaneously, they can also present after trauma to the chest. Symptoms include sudden, severe chest pain; dyspnea; sweating; anxiety; and fatigue. Vital signs
show hypotension, tachycardia, and tachypnea.
Examination shows decreased breath sounds and hyperresonance over the affected side, tracheal deviation to the opposite side, weak peripheral pulses, and faint heart sounds.
The diagnosis should be made on the physical exam results. Although the diagnosis can be
confirmed with FAST ultrasound or portable chest X-ray, treatment should not be delayed
for these studies.
Management
n
n
n
eedle thoracostomy should be ordered after absent breath sounds are discovered. “Whoosh
N
of air” confirms the diagnosis.
Tube thoracostomy (also ordered as “Chest tube”) should be ordered immediately after needle thoracostomy to prevent recurrence. Chest X-ray should be ordered after thoracostomy
to confirm tube placement.
Oxygen, IV fluids, and pain relief with morphine are optional during the time frame of this
case but are recommended. End orders, including routine labs, troponin, and counseling, are
also optional and unlikely to add significantly to your score but are recommended especially
if the history shows the patient is a smoker or overweight.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Chest, Heart •Exam: Additional
•Chest X-ray, portable
•Needle thoracostomy
•Normal saline, 0.9% NaCl
•Tube thoracostomy
•Morphine, intravenous, one time/bolus
•Oxygen
•Pulse oximetry
•Chest X-ray, portable (after tube
•Blood pressure monitor
thoracostomy)
•Cardiac monitor
•Initial management in the ED with change to intensive care unit after tube
thoracostomy.
•Treatment should be initiated in less than 15 minutes of simulated time. If you
do nothing, a negative patient update screen appears in 15 minutes.
Orders
Exam
Orders
Clock
Orders
Clock
Exam
Orders
Clock
Location
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Chest, Heart
Needle thoracostomy, Oxygen
Advance with next available result to results of needle
thoracostomy.
Tube thoracostomy, Intravenous access, Morphine, Normal
saline 0.9% NaCl
Advance with next available result to tube thoracostomy results.
General. Skin, HEENT, Chest, Heart, Abdomen, Extremities ±
Others
Chest X-ray portable, Check blood pressure
Advance with next available result to chest X-ray results.
Change to intensive care unit
Advance with next available result to case end.
CBC, BMP, Troponin, Counsel family/patient
4—USMLE PRIMUM® CCS CASES
15
Case #2
Location: Office
Chief Complaint: Knee pain and swelling
Case introduction
Initial vital signs
Initial history
•A 33-year-old white woman arrives at the office for a 2-week history of
increasing pain in her knees.
•Unremarkable.
•The patient has had increasing pain in her knees, particularly over the past
several days. Her knees are now swollen and interfere with her ability to
walk. She has had aches and joint stiffness in her wrists, hands, and feet
over the past month. The symptoms are worse in the morning particularly
when she gets out of bed. She has also had increasing fatigue and
weakness over the past 3–4 months. The symptoms make it difficult to
take care of her family. She is sexually active with her spouse only.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are
unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; limping; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae,
external auditory canals, and tympanic membranes, normal. Nose
and mouth normal. Pharynx normal. Neck supple; no masses or
bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Extremities/Spine
Bilateral tenderness and swelling of knees, wrist, and hand joints with
decreased range of movement. Peripheral pulses normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
exams normal. Cerebellar function normal. Deep tendon reflexes
normal. Limps while walking.
What is the suspected diagnosis, and what are the next steps in management?
16
I—INTRODUCTION
Case #2: Rheumatoid Arthritis
Keys to Diagnosis
n
n
n
To practice this case, go to Case #2 in the USMLE Primum® software. Look for a patient with
a chronic history of bilateral, symmetric swelling and tenderness in distal joints (hands, wrist,
feet, knees). In addition, there are generalized chronic symptoms such as fatigue and weakness.
On exam, affected joints will show warmth, swelling, tenderness, and decreased range of
movement.
Diagnosis is supported by rheumatoid factor, ESR and cyclic citrullinated antibody.
CBC, ANA, arthrocentesis, and synovial fluid studies should be ordered to rule out other
­differentials.
Management
n
n
n
SAID (ibuprofen) or corticosteroid (prednisone) to reduce pain and inflammation
N
DMARDs (methotrexate) to slow joint damage and improve joint function. Monitor CBC,
LFT, and renal function (BMP) every 3 months on methotrexate. Avoid methotrexate if
pregnancy is a possibility; use etanercept or sulfasalazine instead.
Advise patient to exercise or consult physical therapy to prevent joint deformity and loss of
joint function.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•CBC with differential
•CRP, serum
•Rheumatoid factor
•Urinalysis
•Cyclic citrullinated peptide
•Uric acid, serum
antibody
•TSH, serum
•ANA, serum
•LFT
•ESR
•BMP
•Arthrocentesis
•Synovial fluid analysis
•Synovial fluid, culture
•X-rays (of affected joints)
•NSAID (Ibuprofen) oral continuous •Consult, rheumatology
or Steroid (Prednisone)
•Counsel family/patient
•DMARD (Methotrexate or
•Reassure patient
sulfasalazine) oral, continuous
•Advise patient, exercise program
(or Consult physical medicine)
•Regular monitoring for response to therapy and side effects of medications—
orders outside of time frame of the case
•Office
•Initial therapy should be started within 4 days. If you do nothing, a negative
update screen appears in 4 days.
Exam
Orders
Clock
Orders
Clock
Exam
Clock
End Orders
Extremities ± Others
CBC, Rheumatoid factor, Cyclic citrullinated peptide, ANA, ESR,
Arthrocentesis, Synovial fluid (analysis and culture), X-rays of
affected joints, Ibuprofen
Reschedule patient in 3 days after all results are reported.
Methotrexate (or other DMARD), Advise patient exercise program
(or Consult physical medicine), LFT, BMP, Counsel patient/
family, Reassure
Reschedule patient in 2 weeks to reassess exam.
Extremities ± Others
Reschedule patient in 1–2 months for follow-up exam and labs.
Case will end before next appointment.
Consult, rheumatology
4—USMLE PRIMUM® CCS CASES
17
Case #3
Location: Emergency Department
Chief Complaint: Chest pain radiating to the back
Case introduction
Initial vital signs
Initial history
•A 64-year-old African American man is brought to the emergency department
for severe chest pain.
•Pulse: 114 beats/min, Bounding
•Respiratory rate: 24/min
•Blood pressure, systolic: 192 mm Hg
•Blood pressure, diastolic: 94 mm Hg
•The patient experienced sudden, acute onset of left-sided chest pain that began
30 minutes ago while sitting at his desk at work. The pain is sharp and constant
and radiates to the back and left jaw. Nothing relieves the pain, which is rated
10 on a 10-point scale. He has not experienced this type of chest pain in the
past. He is mildly short of breath and nauseous.
•Past medical history of hypertension and hyperlipidemia.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
99% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed; well nourished; diaphoretic; in acute distress from chest pain.
HEENT/Neck
Normocephalic. Vision normal. Funduscopic examination shows arteriovenous
nicking without hemorrhage. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth normal.
Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation. Cardiac monitor
leads in place.
Heart/
Tachycardia; Prominent apical impulse and indistinct S2 heart sound. S4 heart
Cardiovascular
sound present at apex. Diastolic decrescendo murmur present at left sternal
border. Central and peripheral pulses bounding. No jugular venous distention.
Blood pressure equal in both arms
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
18
I—INTRODUCTION
Case #3: Aortic Dissection
Keys to Diagnosis
n
n
n
o practice this case, go to Case #3 in the USMLE Primum® software. Look for a patient
T
with acute onset of severe, sharp, or tearing chest pain, left-sided, often radiating to the jaw
and back. Past medical history usually shows hypertension. Vital signs show hypertension,
tachycardia, and tachypnea.
Exam shows bounding pulses, prominent apical impulse, diastolic decrescendo murmur
(aortic regurgitation), S4 heart sound. HEENT shows AV nicking from hypertension.
Diagnosis and initial management are based on history and exam. Order ECG and troponin
to help rule out MI, D-dimer to rule out pulmonary embolism, and routine labs: CBC, BMP,
type and crossmatch blood. Diagnosis is confirmed by imaging (Chest CT or echocardiogram) once the blood pressure is stabilized.
Management
n
n
n
ontrol hypertension with beta blocker—esmolol IV (or other antihypertensive such as
C
­nitroprusside); relieve pain with IV morphine.
Primary treatment with open heart surgery (or thoracic surgery consult) after blood pressure
is ­stabilized and diagnosis confirmed with imaging.
Monitor vital signs.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, HEENT, Chest, Heart
•CBC
•ECG, 12-lead
•BMP
•Chest X-ray, portable
•PT/PTT
•Chest CT (or other imaging)
•Troponin I
•D-dimer, plasma
•Esmolol hydrochloride, IV, continuous
•Intravenous access
(or nitroprusside sodium)
•Oxygen
•Morphine, IV, one-time
•Open heart surgery (automatic consult,
surgery, cardio thoracic)
•Type and crossmatch, blood
•Cardiac monitor
•Check vital signs
•Blood pressure monitor
•Pulse oximetry
•Emergency department; patient will be taken to operating room by surgery.
•Diagnosis and management should be instituted within 2 hours of simulated
time. If you do nothing, you will get a negative feedback screen in 2 hours.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, HEENT, Chest, Heart, Extremities
Chest X-ray, ECG, Troponin, D-dimer, CBC, BMP, PT/PTT,
Intravenous access, Morphine, Oxygen
Advance to Chest X-ray results
Esmolol (or nitroprusside or labetalol)
Advance clock to additional results and to check if vital signs
have improved.
Vital signs, Chest CT with contrast (or echocardiography)
Advance clock to chest CT results.
Open heart surgery, type and crossmatch blood
Advance to surgical consult and case end.
None
4—USMLE PRIMUM® CCS CASES
19
Case #4
Location: Office
Chief Complaint: Shortness of breath, cough and wheeze
Case introduction
Initial vital signs
Initial history
•A 5-year-old Latina girl is brought to the office by her mother for a 2-day history of cough, wheezing, and shortness of breath.
•Pulse: 112 beats/min
•Respiratory rate: 31/min
•The mother says the patient has been coughing and wheezing over the past
2 days, which are worsening with increased shortness of breath. She has had
these symptoms over the past several years, usually more in the morning or
when she plays outside, and they generally resolve on their own. She has no
history of fever, chills, sputum with cough, earache, or sore throat.
•Past medical history includes ear infections, bronchitis, hay fever allergies, and
eczema.
•Developmental history, family history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; wheezing and in mild respiratory distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae and external auditory canals,
normal. Tympanic membranes with scarring. Nasal mucosa edematous.
Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Bilateral, mild, intercostal retractions. Bilateral expiratory wheezes and
hyperresonance to percussion. Prolonged expiratory phase. No crackles.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
20
I—INTRODUCTION
Case #4: Asthma
Keys to Diagnosis
n
n
n
o practice this case, go to Case #4 in the USMLE Primum® software. Look for a young child
T
with acute and chronic history of cough, wheezing, and shortness of breath. Symptoms are
typically worse when outside or with exercise. Often there is a history of allergies, infections,
previous hospitalizations, or ear infections. Vital signs show tachycardia and tachypnea.
Exam shows intercostal retraction, hyperresonance to percussion, expiratory wheezes, and
prolonged expiratory phase on chest exam.
The diagnosis is based primarily on history and exam. Peak flow is optional but typically
reduced.
Management
n
n
n
ssess oxygen status with either pulse oximetry or ordering oxygen.
A
Treat with inhaled bronchodilator (albuterol) plus oral steroid (prednisone).
Counseling about asthma care and side effects of medication. Reassess lung exam (and peak
flow) after initial bronchodilator therapy.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam: Lungs ± Others
•Albuterol, inhalational
•Prednisone, oral
•Counseling, asthma care
•Counsel parent, side effects of
medication
•Pulse oximetry
•Lung exam
•Office
•Peak flow
•Oxygen
•Counsel patient/family
•Reassure patient
•Transfer to ED if unresponsive to initial
medications
•Diagnosis and management should be instituted within 12 hours of
simulated time. If you do nothing, you will get a negative feedback screen
in 12 hours.
Exam
General, Skin, Lymph nodes, HEENT, Chest, Heart,
Abdomen, Extremities
Orders
Pulse oximetry, Peak flow
Clock
Advance to peak flow results.
Orders
Albuterol, Prednisone
Clock
Advance clock 10 minutes.
Exam
Chest
Orders
Peak flow, Vital signs, Counseling asthma care, Counsel
parent side effects of medication, Counsel family/
patient, Reassure patient
Clock
Advance clock 1 hour.
Exam
Chest
Orders
Vital signs, Peak flow
Clock
Advance to peak flow results and reschedule patient for
follow-up visit in one day to case end.
End Orders
None
4—USMLE PRIMUM® CCS CASES
21
Case #5
Location: Emergency Department
Reason(s) for Visit: Difficulty concentrating, nausea, and vomiting
Case introduction
Initial vital signs
Initial history
•A 28-year-old white woman is brought to the emergency department by
her coworkers for difficulty concentrating, confusion, lethargy, nausea, and
vomiting. She appears acutely ill.
•Temperature: 38.0 degrees C (100.3 degrees F)
•Pulse: 128 beats/min, Thready
•Respiratory rate: 28/min
•Blood pressure, systolic: 92 mm Hg
•Blood pressure, diastolic: 68 mm Hg
•Her coworkers describe worsening confusion, lethargy, and drowsiness over
the past 2 hours, while she was working at her desk as a receptionist. She has
felt nauseous for the past 24 hours and has been vomiting for the past 4 hours.
She has not eaten since yesterday. She felt cold and had chills last night.
•Past medical history of type 1 diabetes diagnosed at age 14 years controlled
with insulin. She has not taken insulin since yesterday.
•She is sexually active with her husband only; There is no history of alcohol or
illicit drug use.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
95% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed, thin; appears acutely ill.
Skin
Dry with poor turgor. Hair and nails normal.
Chest/Lung
Tachypneic. Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or auscultation.
Cardiac monitor leads in place.
Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses thready with tachycardia. No jugular venous distention.
Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. Mild diffuse tenderness. Liver and spleen not
palpable. No hernias.
Neuro/Psych
Drowsy and lethargic. Oriented to person, place, and time. Remainder of
neurologic exam normal.
What is the suspected diagnosis, and what are the next steps in management?
22
I—INTRODUCTION
Case #5: Diabetic Ketoacidosis with Sepsis
Keys to Diagnosis
n
n
n
o practice this case, go to Case #5 in the USMLE CCS Primum® software. Look for a patient
T
with a past medical history of diabetes, but this case may also be presented as a new diagnosis.
Symptoms include nausea, vomiting, confusion, difficulty concentrating, dizziness, blurred vision,
fatigue, or abdominal pain. Vital signs may show fever, tachypnea, tachycardia and hypotension.
Exam generally shows nonspecific findings related to dehydration and drowsiness.
The diagnosis should be suspected based on the history and exam. A fingerstick glucose and
urinalysis should confirm the diagnosis. Evaluation of acidosis as well as secondary diagnoses
such as infections, sepsis, myocardial infraction, pneumonia, or DVT/PE should be performed.
Management
n
n
n
orrect fluid loss with intravenous fluids, correct hyperglycemia with insulin, and correct
C
electrolyte disturbances (particularly potassium).
Monitor glucose, electrolytes, and ABG hourly once treatment is initiated.
Treat infections with broad-spectrum antibiotics—Aminoglycoside (gentamicin) + 3rd generation cephalosporin (cefotaxime) or numerous other antibiotic combinations acceptable.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
ADDITIONAL ORDERS
•Fingerstick glucose, stat, every 1 hr •Ketone bodies, serum, quantitative
•Urinalysis
•Beta-hydroxybutyrate, blood
•ABG, stat, every 1 hr
•Troponin I
•BMP, stat, every 1 hr
•D-dimer, plasma
•Osmolality, serum
•Phosphorus
•CBC
•Magnesium
•Blood culture
•LFT
•Urine culture
•HCG, beta, urine, qualitative (if female)
•Urine Gram stain
•Normal saline solution, 0.9% NaCl
•Intravenous access
•Insulin, regular, IV
•Counseling, diabetes education
•Gentamicin, IV
•Cefotaxime sodium, IV
•Blood pressure monitor,
•Cardiac monitor
•Fingerstick glucose (hourly)
•Pulse oximetry
•BMP (hourly)
•ABG (hourly)
•After initial diagnosis and management, change location to ICU for monitoring.
•Initial management should be initiated within the first hour. If you do nothing,
you will get a negative feedback screen at 4 hours.
SEQUENCING Orders
Exam
Orders
Clock
Orders
Clock
Location
Orders
Exam
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Fingerstick glucose, ABG, Urinalysis, CBC, BMP, Osmolality, HCG
urine (if female), Beta-hydroxybutyrate, Ketone bodies serum,
Troponin I, D-dimer, Blood culture, Urine Gram stain, Urine culture,
Phosphorus, Magnesium
Advance the clock “with next available result”.
After fingerstick glucose result, order normal saline and regular insulin
IV. After signs of UTI on UA, order appropriate antibiotics (Ex.
Gentamicin + Cefotaxime).
Advance clock to 1 hour after insulin ordered for patient update.
Transfer to ICU.
Fingerstick glucose every 1 hr, ABG every 1 hr, BMP every 1 hr
Interval/Follow-up, General, Skin, Chest, Heart, Abdomen
Advance clock “with next available result” to monitor lab results, get
additional patient update at 4 hours after insulin started and case end.
Counseling orders (advise patient no smoking, diabetes education).
4—USMLE PRIMUM® CCS CASES
23
Case #6
Location: Emergency Department
Chief Complaint: Altered mental status with seizures
Case introduction
Initial vital signs
Initial history
•A 23-year-old pregnant African American woman is brought to the emergency
department by her husband for confusion, loss of consciousness, and seizure.
•Temperature: 37.3 degrees C (99.3 degrees F)
•Pulse: 110 beats/min
•Blood pressure, systolic: 184 mm Hg
•Blood pressure, diastolic: 108 mm Hg
•The patient is gravida 1, para 0 and in her 37th week of pregnancy. She
was found by her husband having a seizure 15 minutes before arrival,
which lasted for about 5 minutes. She is currently conscious but appears
confused. She has complained of headaches for the past 4 days and swollen feet 2 weeks. She has no prior history of seizures and has had normal
routine prenatal care.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, pregnant; appears confused.
HEENT/Neck
Normocephalic. Funduscopic examination shows diffuse vasospasms. Ears,
including pinnae, external auditory canals, and tympanic membranes,
normal. Minor tongue laceration. Pharynx normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
Tachycardia. S1 and S2 normal. S4 present with grade 2 systolic ejection
murmur prominent at the left sternal border. Central and peripheral pulses
bounding. No jugular venous distention.
Abdomen
Gravid. Fundal height 38 cm. Estimated fetal weight 2650g (5.8 lb). Fetus
cephalic by palpation. Fetal heart rate 145 beats/min. Bowel sounds
normal. No tenderness. Liver and spleen not palpable.
Genitalia
Cervix dilated 2 cm; 60% effaced; midposition; vertex at −2 station.
Membranes intact. No adnexal masses or tenderness.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. 4+ pitting edema
to the knees. Peripheral pulses bounding. No joint deformity or warmth.
Neuro/Psych
Conscious but oriented only to person. Findings on cranial nerve, motor, and
sensory examinations normal. Cerebellar function normal. Deep tendon
reflexes exaggerated 4+ bilaterally.
What is the suspected diagnosis, and what are the next steps in management?
24
I—INTRODUCTION
Case #6: Eclampsia with Fetal Distress
Keys to Diagnosis
n
n
n
To practice this case, go to Case #6 in the USMLE CCS Primum® software. Look for a pregnant patient who presents with seizures and altered mental status or loss of consciousness.
Vital signs show hypertension, tachycardia, and low-grade fever.
On exam, funduscopy shows vasospasms, heart exam shows systolic ejection murmur, extremities show pitting edema, and neuro exam shows hyperactive reflexes.
Diagnosis is based mainly on history and exam. Labs should be ordered to rule out HELLP
syndrome (CBC, LFT) and DIC (PT/PTT, fibrinogen).
Management
n
n
n
agnesium, IV to prevent seizures.
M
Blood pressure control with medications (e.g., hydralazine, IV).
Fetal delivery with cesarean section (or obstetrics/gynecology consult) when blood pressure
stabilized.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, HEENT, Heart,
•PT/PTT
Lung, Extremities, Neuro
•Fibrinogen, plasma
•Urinalysis
•CBC
•BMP
•LFT
•Magnesium sulfate, IV
•Foley catheter
•Hydralazine hydrochloride, IV
•Type and crossmatch, blood
•Cesarean section (or Consult,
obstetrics/gynecology)
•Blood pressure monitor
•Cardiac monitor
•Fetal monitor
•Pulse oximetry
•Urine output
•The management time frame of this case will take place in the ED.
•Initial management should be performed within 1 hr of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Exam
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, HEENT, Lung, Heart, Abdomen, Genitalia,
Extremities, Neuro
Fetal monitor, CBC, BMP, LFT, PT/PTT, Urinalysis, Fibrinogen,
Magnesium sulfate, Hydralazine, Foley catheter, Urine
output
Advance clock 30 min to results of studies.
Vital signs every 1 hour
Advance clock to check vital signs.
Consult, obstetrics/gynecology (or Cesarean section)
Advance clock 15 minutes to results of consult.
Interval/Follow-up, General, Heart, Abdomen, Genitalia, Neuro
Advance to exam results, additional updates and case end.
None
4—USMLE PRIMUM® CCS CASES
25
TABLE 1 n General management strategy for Emergency Department Cases
• For emergency department cases, use the following general strategy:
1. ORDER
Begin with monitoring orders if abnormal vital signs present:
• Blood pressure monitor for hypotension or hypertension
• Cardiac monitor for abnormal heart rate
• Pulse oximetry for abnormal respiratory rate
2. EXAM
Order a limited physical exam.
• Chest and Heart exam are usually mandatory.
•In some cases, the diagnosis can be made on the physical exam, such as
tension pneumothorax.
3. ORDER
Order initial diagnostic studies that provide results within 20 to 30 minutes.
•Look at the key orders page of each chapter to see which orders provide rapid
results. Always consider HCG, urine in a reproductive-age woman.
• If the patient is in severe pain, order pain medications.
4. CLOCK
Advance clock to the results of the initial orders.
• Advance clock “with next available result.”
5. ORDER
Order therapy. If diagnosis is still unknown, order more studies.
6. CLOCK
Advance clock to results of therapy.
7. ORDER
Recheck any abnormal vital signs, exam findings, or diagnostic studies to ­confirm
improvement with therapy.
8. LOCATION
Change location if needed.
9. CLOCK
Advance clock to end of case.
TABLE 2 n General management strategy for Office Cases
• For office cases, use the following general strategy:
1. EXAM
Begin with a thorough physical exam, unless abnormal vital signs are present.
2. LOCATION
Determine if management can be performed in the office as an outpatient or if the
location needs to be changed.
3. ORDER
Order initial diagnostic studies.
•Some diagnostic studies may be reported in less than 30 minutes; others may
take several days.
4. CLOCK
Advance clock to results of diagnostic studies.
•For some cases, advance the clock 30 to 60 minutes to see results of initial
studies at the first office visit if it will affect management (e.g., see Chapter 20,
Vaginal Discharge).
• For most cases, advance the clock to reschedule the patient in 2 to 3 days after
results of diagnostic studies are reported.
5. ORDER
Order therapy, including counseling.
6. CLOCK
Advance clock to get patient updates with results of therapy. Reschedule the
patient if appropriate.
7. ORDER
Recheck any abnormal exam findings or diagnostic studies as needed.
8. CLOCK
Advance clock to case end.
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S E C T I O N
II
CCS Cases by Chief Complaint
C H A P T E R
5
Abdominal Pain
Key Orders*
Time to Results—ED
Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor,
continuous
Cardiac monitor
Urine pregnancy test
Chest X-ray, portable
ECG, 12-lead
ABG
FAST ultrasound
Pulse oximetry
Monitor, continuous blood
pressure cuff
Monitor, cardiac
hCG, beta, urine, qualitative
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
US, focused assessment
sonography for trauma
X-ray, abdomen, acute series
X-ray, chest, PA/lateral
Paracentesis, diagnostic
Paracentesis, therapeutic
X-ray, abdomen, AP
US, abdomen
CT, abdomen/pelvis, with
contrast
CT, abdomen/pelvis, without
contrast
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
US, pelvis, transvaginal
Troponin I, serum
hCG, beta, serum, qualitative
1 min
5 min
Amylase, serum
MRI, abdomen/pelvis, with
gadolinium
MRI, abdomen/pelvis, without
gadolinium
Aortography, abdominal
Barium enema
Laparotomy
Lipase, serum
Laparoscopy
hCG, beta, serum, quantitative
1 hr
1.5 hr
MRA, abdomen
4 hr
Abdominal X-ray, acute series
Chest X-ray, PA/lateral
Abdominal tap, diagnostic
Abdominal tap, therapeutic
Abdominal flat plate X-ray
Abdominal ultrasound
Abdominal CT scan with
contrast
Abdominal CT scan without
contrast
Echocardiography
CBC with differential
BMP
PT/PTT
Transvaginal ultrasound
Troponin I, serum
Pregnancy test, serum,
qualitative
Amylase, serum
Abdominal MRI with gadolinium
Abdominal MRI without
gadolinium
Abdominal aortography
Enema, barium
Laparotomy
Lipase, serum
Laparoscopy
Pregnancy test, serum,
quantitative
Abdominal aorta MRA
5 min
5 min
10 min
15 min
18 min
20 min
20 min
20 min
20 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
45 min
1 hr
1.5 hr
2 hr
2 hr
2 hr
2 hr
2 hr 15 min
3 hr
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
29
5—ABDOMINAL PAIN
Case #7
Location: Emergency Department
Chief Complaint: Abdominal pain in the right upper quadrant
Case introduction
Initial vital signs
Initial history
•A 66-year-old African-American woman is brought to the emergency department by her daughter for worsening abdominal pain over the past 2 days.
•Temperature: 40.1 degrees C (104.2 degrees F)
•Respiratory rate: 28/min
•The patient has been experiencing worsening right upper quadrant abdominal
pain over the past 2 days. The pain is a dull ache that does not radiate. The
pain has been worsening and is now rated a 6 on a 10-point scale. There
is no history of dark stools, vomiting, or diarrhea. She notes occasional
episodes of shaking chills and increasing fatigue. She has had one to two
episodes of shortness of breath on exertion in the past few days. There is no
history of cough or chest pain.
•Past medical history includes diabetes mellitus treated with metformin.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
90% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; appears in mild discomfort.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Dullness to percussion and crackles at right lower base.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
30
II—CCS CASES BY CHIEF COMPLAINT
Case #7: Pneumonia
Keys to Diagnosis
n
n
n
Although typical symptoms include cough, dyspnea, or hemoptysis, on the CCS, look for
an atypical presentation, such as abdominal pain in an elderly or diabetic patient. Additional
symptoms include fatigue and exercise intolerance. Vital signs may show fever, tachypnea,
and tachycardia.
On chest exam, look for rales, rhonchi, decreased breath sounds, or dullness to percussion on
the affected side.
Chest X-ray, PA/lateral is the standard for diagnosing pneumonia. On the CCS, an abdominal
X-ray acute series includes a PA chest X-ray that will also detect lower lobe pneumonia. Sputum
studies can be performed if the patient has a productive cough. Lab tests (CBC, BMP, blood
cultures) are generally not needed for diagnosis unless the patient meets criteria for admission.
Management
n
Antibiotic therapy is the mainstay of treatment. Several options exist, but in general:
For a generally healthy outpatient, use an oral macrolide (azithromycin).
n For outpatients with a comorbid condition (CHF, diabetes, alcoholism, malignancy) or
have been on an antibiotic within 90 days, use an oral fluoroquinolone (ciprofloxacin).
n For a patient admitted to the hospital, use an IV fluoroquinolone (levofloxacin).
Decide whether to admit the patient.
n If the vital signs are normal, pulse oximetry is normal, and chest X-ray shows localized
involvement, then outpatient therapy is adequate.
n If the patient has comorbid conditions and abnormal vital signs such as hypotension or
tachypnea requiring oxygen, IV fluids, or IV antibiotics, then admit to inpatient unit.
n If the patient is septic with severe hypotension, admit to ICU.
n
n
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: lungs, abdomen
•Exam: complete
•Chest X-ray, PA/lateral (or Abdominal
•CBC, BMP, Blood culture, if
X-ray, acute series)
admitted to hospital
•Antibiotic:
•Acetaminophen, oral
•Azithromycin, oral (if outpatient and
•Reassure patient
healthy)
•Advise patient, no smoking
•Ciprofloxacin, oral (if outpatient but
comorbid conditions)
•Levofloxacin, IV (if admitted to hospital)
•Oxygen (if pulse oximetry reduced)
•Pulse oximetry
•Admit to inpatient unit if decreased pulse oximetry or if patient requires
oxygen, IV fluids, or IV antibiotics.
•Diagnosis and management should be instituted within 2 hours of simulated
time.
Orders
Exam
Orders
Clock
Orders
Location
Clock
Exam
Clock
End Orders
Pulse oximetry
General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Rectal, Extremities, Neuro
Oxygen, Chest X-ray, PA/lateral (or Abdominal X-ray acute series)
Advance to X-ray results.
Antibiotic (Levofloxacin or see above), Acetaminophen, Reassure,
Advise patient no smoking CBC, BMP, Blood culture
Change to inpatient unit (if meets criteria).
Advance clock to additional updates and next day.
Interval Hx, Chest
Advance clock to case end
None
31
5—ABDOMINAL PAIN
Case #8
Location: Emergency Department
Chief Complaint: Abdominal pain in the right lower quadrant
Case introduction
Initial vital signs
Initial history
•A 26-year-old white woman is brought to the emergency department by ambulance for severe right lower quadrant abdominal pain that began 3 hours ago.
•Temperature: 38.5 degrees C (101.3 degrees F)
•Pulse: 128 beats/min
•The abdominal pain began earlier in the day as a generalized abdominal pain
then progressed over the past 3 hours to a sharp, severe pain in the right
lower quadrant. Nothing relieves the pain, which is rated 9 on a 10-point
scale. She is nauseous and vomited twice before arriving at the emergency
department. She is sexually active with two men using condoms for contraception. Her last menstrual period was 2 weeks ago.
•Past medical history includes treatment for gonorrhea 2 years ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
98% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; moaning and holding her abdomen in
distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds reduced; no bruits. No masses. Right lower quadrant guarding
and rebound tenderness. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. No adnexal
masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
32
II—CCS CASES BY CHIEF COMPLAINT
Case #8: Acute Appendicitis
Keys to Diagnosis
n
n
n
bdominal pain may begin as central or epigastric before localizing to right lower quadrant.
A
Nausea, vomiting, and loss of appetite are also common symptoms. Vital signs may show
fever or tachycardia.
Examination shows abdominal rebound tenderness, guarding, and possibly decreased bowel
sounds. Genitalia exam is normal.
CT abdomen/pelvis without contrast is the most sensitive/specific study. Ultrasound is
­preferred in pregnant women and in girls. CBC may show leukocytosis. Typical cases may
not need imaging studies, but imaging confirmation is routinely performed.
Management
n
n
n
ppendectomy (by laparoscopy or laparotomy)-generates automatic surgical consult.
A
IV antibiotic prophylaxis (Ampicillin sodium/-sulbactam sodium) or piperacillin-tazobactam.
Supportive care: NPO, IV fluids, correct electrolytes if needed, morphine for pain control,
Promethazine hydrochloride for nausea.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: abdomen, genitalia
•Abdominal ultrasound (or Abdominal
CT if not young woman)
•hCG, beta, urine, qualitative (if
female)
•Normal saline 0.9% NaCl
•Appendectomy (by laparoscopy or
laparotomy)
•Ampicillin sodium/sulbactam
sodium, IV, one-time
•Exam: general, heart, lungs,
rectal
•CBC
•BMP
•Urinalysis
•Intravenous access
•Morphine, IV one-time
•Promethazine hydrochloride,
IV, one-time
•Nothing by mouth
•Reassure patient
•Cardiac monitor, blood pressure monitor, pulse oximetry (if abnormal vital
signs)
•Case is managed in the emergency department and typically ends with
the patient taken to the operating room.
•Diagnosis and management should be instituted within 1 hour of
simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
End Orders
Cardiac monitor, Pulse oximetry, Blood pressure monitor
General, Chest, Heart, Abdomen, Genitalia, Rectal
hCG, Abdominal ultrasound (or CT), Morphine, Promethazine
hydrochloride (if nausea or vomiting)
Advance to ultrasound.
Appendectomy (by laparoscopy or laparotomy), CBC, BMP,
Urinalysis, Nothing by mouth, Ampicillin–sulbactam,
Reassure patient, Normal saline 0.9% NaCl
Advance to appendectomy and case end.
None
33
5—ABDOMINAL PAIN
Case #9
Location: Emergency Department
Chief Complaint: Abdominal pain radiating to back
Case introduction
Initial vital signs
Initial history
•A 52-year-old Latino man is brought to the emergency department by his
wife for worsening abdominal pain over the past 24 hours, which now is
radiating to the back.
•Temperature: 39.0 degrees C (102.2 degrees F)
•Pulse: 130 beats/min
•Respiratory rate: 27/min
•Blood pressure, systolic: 90 mm Hg
•Blood pressure, diastolic: 55 mm Hg
•The abdominal pain began yesterday with mild nausea. Overnight and
throughout today, the pain and nausea worsened with three episodes
of vomiting. The last vomiting episode had bilious vomit. The abdominal
pain is located in the left upper quadrant and is now severe, rated 9 on a
10-point scale. The pain radiates to the back, and leaning forward mildly
improves the pain.
•Past history of cholecystitis related to gallstones.
•He drinks six beers a day for the past 15 years. Smokes 5 to 10 cigarettes
a day; no history of illicit drug use.
•Family history and review of systems otherwise unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
98% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed; holding his abdomen in distress.
Skin
Decreased turgor. No nodules or other lesions. Hair and nails normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. Basilar rales bilaterally.
Abdomen
Bowel sounds reduced; no bruits. Mild abdominal distension. Tenderness
and guarding in the epigastric and left upper quadrant region. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
Case #9: Acute Pancreatitis
Keys to Diagnosis
n
n
n
Look for a patient with severe abdominal pain, epigastric or left upper quadrant, which often
radiates to the back. Additional symptoms include nausea, vomiting, anorexia, and diarrhea.
Look for a history of gallstones or alcohol use. Vital signs show fever and tachycardia.
On exam, abdominal distention with tenderness and guarding in the upper quadrant is often
seen. Bowel sounds are typically reduced because of ileus. No occult blood on rectal exam.
Abdominal CT scan is the radiologic test of choice in severe acute pancreatitis for assessing
complications and providing prognostic information. Abdominal ultrasound and X-ray are
less useful in this setting. Lab tests such as amylase, lipase, LFT, and others listed below
provide additional support and help determine prognostic information.
Management
n
n
n
n
Provide aggressive supportive care: Oxygen, NPO, IV fluids, Monitor urine output, Nausea
control (Promethazine) and pain relief-Hydromorphone hydrochloride (Dilaudid).
Antibiotic use is controversial. Currently not recommended for prophylaxis; recommended
only if acute necrotizing pancreatitis is present.
Endoscopic retrograde cholangiopancreatography (ERCP) if imaging and laboratory studies
consistent with severe acute gallstone pancreatitis.
Surgical consult in gallstone pancreatitis to evaluate if the patient should have cholecystectomy.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Chest, Heart,
Abdomen
•CT, abdomen/pelvis without
contrast
•Amylase, serum
•Lipase, serum
•BMP
•CBC
•LFT
•ABG
•Troponin I
•ECG, 12-lead
•PT/PTT
•Triglycerides, blood
•Phosphorus, serum
•Magnesium, serum
•Urinalysis
•Blood culture
•hCG, beta, urine, qualitative, stat (if female)
•Normal saline solution, 0.9% NaCl •Nasogastric tube
•Oxygen
•Consult, general surgery (or ERCP)•Nothing by mouth
if gallstones on imaging
•Hydromorphone Hydrochloride
•Promethazine hydrocholoride (Phener(Dilaudid), IV
gan), IV for nausea
•Blood pressure monitor
•Vital signs
•Pulse oximetry
•Foley catheter
•Cardiac monitor
•Urine output
•Transfer to ICU for initial monitoring then to inpatient unit once patient has stable
vital signs. Patient may be taken to surgery with surgical consult.
•Initial diagnosis and management including pain relief and IV fluids should be
instituted within 1 hour of simulated time.
Orders
Exam
Orders
Clock
Orders
Location
Clock
Exam
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, Chest, Heart, Abdomen, Rectal
Abdominal CT scan, BMP, Amylase, Lipase, CBC, Troponin, ECG,
ABG, LFT, PT/PTT, Triglycerides, Oxygen, IV access, Normal
saline, Hydromorphone, Promethazine
Advance to results of CT scan.
Consult, general surgery (if gallstones), Foley catheter, Urine output
Change to ICU
Advance to additional results and patient updates.
General, Abdomen +/- Others
Advance to additional updates and case end.
Consider counseling orders
35
5—ABDOMINAL PAIN
Case #10
Location: Emergency Department
Chief Complaint: Abdominal pain and chest pain
Case introduction
Initial vital signs
Initial history
•A 9-year-old African-American boy is brought to the emergency department
by his mother for severe abdominal and chest pain over the past 2 hours.
•Temperature: 38.3 degrees C (101.0 degrees F)
•Other vital signs unremarkable
•The pain has been worsening over the past 2 hours and is located in the
chest, abdomen, and arms. Nothing relieves the pain, which is rated 9 on
a 10-point scale. The patient had an upper respiratory tract infection that
began 3 days ago. There is no history of constipation or diarrhea.
•Past medical history of sickle cell anemia diagnosed at age 1. All vaccinations, including pneumococcal and Hemophilus, are up to date. Medications
include prophylactic penicillin.
•Family history, developmental history, and review of systems are otherwise
unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in distress, holding his chest and abdomen.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Basilar rales present.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Alert; neurologic findings normal.
What is the suspected diagnosis, and what are the next steps in management?
36
II—CCS CASES BY CHIEF COMPLAINT
Case #10: Sickle Cell Anemia with Vaso-Occlusive Crisis
Keys to Diagnosis
n
n
n
The diagnosis is based on history of pain in a patient with known sickle cell anemia. Crisis
is often precipitated by dehydration, infection, pregnancy, stress, or cold weather. Vital signs
will show fever with acute chest syndrome.
Examination is generally unremarkable.
Order chest X-ray looking for acute chest syndrome (pulmonary infiltrates on CXR, chest
pain, and fever). Order sputum studies if productive cough. If CBC shows severe anemia,
order reticulocyte count looking for aplastic crisis (low reticulocyte count). In older patients,
consider abdominal ultrasound to evaluate for gallstones.
Management
n
n
n
n
n
n
Treatment is mainly supportive: hydration with IV fluids, pain control with morphine and
NSAIDs, oxygen if hypoxia, incentive spirometry.
Hydroxyurea is used in the chronic setting after initial management to prevent future attacks.
Transfusion if significant anemia or thrombocytopenia present (aplastic crisis).
Empiric antibiotics in acute chest syndrome (Azithromycin).
Hematology consult optional.
If gallstone cholecystitis present, consider surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
ADDITIONAL ORDERS
•Chest X-ray, PA/lateral
•CBC
•Reticulocyte count
•Blood culture
•Urine culture
•Exam: Additional
•Abdominal ultrasound
•ECG
•Troponin
•BMP
•Urinalysis
•Amylase, Lipase
•hCG, beta, urine, qualitative (if female)
THERAPY
•Oxygen
•Hydroxyurea, oral
•Normal saline 0.9% NaCl
•Ibuprofen
•Morphine, IV
•Incentive spirometry
•Antibiotics (if acute chest
•Transfusion RBC (only if severe anemia)
syndrome—Azithromycin, IV)
•Reassure patient
MONITORING •Pulse oximetry
•CBC
•Urine output
LOCATION
•Initial management in the emergency department with change to inpatient unit for
monitoring.
TIMING
•Diagnosis and management should be instituted within 2 hours of simulated time.
SEQUENCING Orders
Exam
Orders
Clock
Orders
Clock
Location
Exam
Orders
Clock
End Orders
Pulse oximetry
General, Skin, Lungs, Heart, Abdomen, Rectal ± Others
Chest X-ray PA/lateral, Oxygen, Intravenous access, Normal saline
0.9% NaCl, Morphine
Advance to chest X-ray results.
CBC, Reticulocyte count, Abdominal ultrasound (if possible cholecystitis),
ECG, BMP, Troponin, Amylase, Lipase, LFT, Blood culture, Urinalysis,
Urine culture, Type and crossmatch blood, Antibiotics (Azithromycin)
Advance to additional results and patient update.
Change to inpatient unit.
General, Chest +/- Others
Incentive spirometry, Reassure, Counsel family
Advance to additional patient updates and case end.
Hydroxyurea, any follow-up labs needed.
37
5—ABDOMINAL PAIN
Case #11
Location: Emergency Department
Chief Complaint: Abdominal pain and vaginal spotting
Case introduction
Initial vital signs
Initial history
•A 22-year-old white woman is brought to the emergency department by her
roommate for worsening abdominal pain over the past 6 hours.
•Temperature: 38.0 degrees C (100.5 degrees F)
•Pulse: 105 beats/min
•Blood pressure, systolic: 90 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient has had worsening abdominal pain over the past 6 hours that is
now a constant, sharp, and focused pain in the right lower quadrant. Nothing
relieves the pain, which is rated 10 on a 10-point scale. She has had occasional episodes of vaginal spotting over the past 2 days. There is no history of
constipation or diarrhea. She is sexually active with three men with occasional
use of condoms for contraception. Her last menstrual period was 6 weeks
ago.
•Past medical history includes treatment for chlamydia infection 6 months ago.
She is on no current medications.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in acute distress, moaning and holding her
abdomen.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms
Abdomen
Bowel sounds normal; no bruits. Right lower quadrant tenderness on
palpation. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal lesions. Cervical os closed with cervical motion
tenderness present. Uterus mildly enlarged. Right adnexal mass with
tenderness.
What is the suspected diagnosis, and what are the next steps in management?
38
II—CCS CASES BY CHIEF COMPLAINT
Case #11: Ectopic Pregnancy
Keys to Diagnosis
n
n
n
Look for the classic triad of abdominal/pelvic pain, amenorrhea, and vaginal bleeding.
­Additional symptoms may include nausea, breast fullness, fatigue, heavy cramping, shoulder
pain, and dyspareunia. Vital signs may be normal or show hypotension and tachycardia.
On examination, look for abdominal tenderness, adnexal mass and tenderness, enlarged
uterus, and cervical motion tenderness.
The most important diagnostic studies are hCG urine to confirm pregnancy and transvaginal
ultrasound to rule out intrauterine pregnancy.
Management
n
Treatment depends on whether the patient is stable or unstable.
If unstable, as in this case, proceed to laparotomy or laparoscopy. Order pain relief
(morphine).
n If stable, consider laparoscopy or medical management with methotrexate. Consider
methotrexate if the patient is compliant; adnexal mass <3.5cm; quantitative hCG <15,000;
and there is no history of renal disease, liver disease, or cytopenia. (Order quantitative
hCG, CBC, BMP, and LFT before administering medication and advise against alcohol,
NSAIDs, and sex.)
Monitor quantitative hCG weekly until results are negative.
n
n
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: genitalia, abdomen
•hCG, beta, urine, qualitative
•Transvaginal ultrasound
•Exam: lungs, heart
•CBC
•BMP
•PT/PTT
•hCG, beta, serum, quantitative
•Laparotomy
•Consult, obstetrics and gynecology
•Type and crossmatch, blood
•Morphine, IV, one-time/bolus
•Normal saline, 0.9% NaCl (if
•RhoGAM, IM
hypotension)
•Advise patient, safe sex techniques
•Blood pressure monitor,
•Monitor quantitative hCG weekly until
continuous (if hypotension)
negative
•Initial management in emergency department with patient taken to surgery
if unstable.
•If stable and management with methotrexate desired, can be treated as an
outpatient.
•Diagnosis and management should be instituted within 2 hours of simulated
time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor (if hypotension)
Abdomen, Genitalia, General, Heart, Lungs
hCG urine, Morphine
Advance to hCG result.
Transvaginal ultrasound, Intravenous access, Normal saline, CBC,
BMP, PT/PTT
Advance to ultrasound result.
Laparotomy (or laparoscopy or Consult Ob-Gyn), Type and
crossmatch blood
Advance to consult and case end.
hCG serum quantitative, RhoGAM; Advise patient safe sex
techniques
39
5—ABDOMINAL PAIN
Case #12
Location: Office
Chief Complaint: Epigastric pain and fatigue
Case introduction
Initial vital signs
Initial history
•A 62-year-old African-American man presents to the office with a 3-month history of epigastric pain.
•Height: 168 cm (66.0 in)
•Weight: 97.5 kg (215.0 lb)
•Body mass index: 34.7 kg/m2
•The patient describes intermittent epigastric pain over the past 3 months generally occurring after meals. He has had some epigastric discomfort for more
than 2 years. The pain is usually relieved with over-the-counter antacids. The
pain is associated with nausea, occasional episodes of vomiting, and belching.
The pain appears to worsen at night when lying down. He has also noticed
increasing fatigue and tiredness over the past 3 months. There is no history of
fever, constipation, or diarrhea.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
40
II—CCS CASES BY CHIEF COMPLAINT
Case #12: Gastroesophageal Reflux Disease/Barrett
Esophagus
Keys to Diagnosis
n
n
n
ymptoms include heartburn, regurgitation, dysphagia, and reflux. Less commonly, may see
S
chronic cough, chest pain, and bronchospasms. Vital signs may show the patient is overweight.
Examination is generally unremarkable and should not show occult blood on rectal exam.
The diagnosis is usually made on history. Endoscopy is generally recommended one
time in patients age older than 50 years with a history of chronic GERD to evaluate for
­complications, such as ulcers, Barrett esophagus, and cancer.
Management
n
n
n
n
n
n
reatment for GERD and Barrett esophagus without dysplasia is similar.
T
Proton pump inhibitors are first line (e.g., omeprazole).
Lifestyle modifications are imperative—avoid smoking and alcohol, advise sitting up after
meals, diet and exercise for weight loss.
Patients with Barrett esophagus should undergo surveillance endoscopy every 2 years or less.
Testing and treating for Helicobacter pylori in GERD has not been shown to improve
­symptoms.
If biopsy shows high-grade dysplasia, refer for surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Endoscopy, upper
•ECG, 12-lead (if chest pain present)
gastrointestinal
•Esophageal biopsy
•Omeprazole, oral, continuous
•Diet calorie restricted (if BMI elevated)
•Advise no smoking
•Advise exercise program
•Advise limit alcohol intake
•Reassure patient
•Advise sit upright after meals
•Advise side effects of medication
•Patients with Barrett esophagus should undergo surveillance endoscopy every
2 years or less.
•Office with outpatient management.
•Diagnosis and management should be instituted within 4 days of simulated
time.
Exam
Orders
Clock
Orders
Clock
End Orders
General, Heart, Lung, Abdomen, Rectal ± Others
Endoscopy upper gastrointestinal, Esophageal biopsy
Advance clock (reschedule patient) after results of endoscopy
and biopsy.
Omeprazole, Diet calorie restricted, Advise side effects of
medication, Advise exercise program, Advise no smoking,
Advise limit alcohol, Advise sit upright after meals, Counsel
patient, Reassure patient
Advance clock to see patient as needed for patient updates and
case end.
None
41
5—ABDOMINAL PAIN
Case #13
Location: Emergency Department
Chief Complaint: Abdominal pain and vomiting in an infant
Case introduction
Initial vital signs
Initial history
•An 18-month-old Native American boy is brought to the emergency department by his mother for abdominal pain and vomiting over the past 3 hours.
•Unremarkable
•The mother describes progressively worsening abdominal pain over the past
3 hours with increased fussiness and crying. The pain occurs for 10 to 15
minutes at a time and then is relieved for 30 to 40 minutes. During painful
episodes, the patient lies down and pulls his legs toward his abdomen. The
patient had three episodes of vomiting before arrival with food and bile in the
vomit but no blood. The mother also noted dark, loose stools. There has been
no change in diet and no recent travel history. There is no fever, constipation,
diarrhea, or recent history of infection.
•Past medical history is unremarkable.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed infant, crying and fussy.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds reduced. Tenderness and fullness present in the right upper
quadrant. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses. Currant jelly stool; Occult blood positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
42
II—CCS CASES BY CHIEF COMPLAINT
Case #13: Intussusception
Keys to Diagnosis
n
n
n
ook for a child younger than 2 years old with the classic triad of abdominal pain, vomiting,
L
and bloody stools. The pain typically is cyclical, lasting 10 to 15 minutes, and the patient
often draws their legs up to the abdomen. Additional symptoms include lethargy; diarrhea,
which may be bloody; and recent viral infection.
Examination may show a “sausage-like” abdominal mass in one quadrant (usually right upper quadrant). Also, look for bloody or “Currant jelly” stools.
Initial screening with ultrasound or abdominal X-rays. Ultrasound is more commonly used
and will more clearly identify the intussusception. X-rays may show a soft tissue mass and
dilated loops of bowel (obstruction). If ultrasound or X-ray results are normal, intussusception is unlikely. CBC and BMP for screening.
Management
n
n
n
arium enema is both diagnostic and therapeutic. Note: air enema is not an option on the
B
CCS. 24-hour observation in hospital after reduction is recommended.
IV access, normal saline, NPO, and pain relief.
If barium enema fails or if perforation is present, surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: abdomen, rectal
•Abdominal ultrasound (or X-ray)
•Barium enema
•CBC
•BMP
•Intravenous access
•Normal saline
•NPO
•Morphine (or Ibuprofen)
•Monitor in hospital for 24 hours after reduction.
•Management in ED with hospital admission for monitoring
•Diagnosis and management should be instituted within 2 hours of simulated
time.
Exam
Orders
Clock
Orders
Clock
Location
Clock
Exam
Clock
End Orders
Abdomen, Rectal, Heart, Lungs ± Others
Abdominal ultrasound
Advance to ultrasound.
Barium enema, Intravenous access, Normal saline, NPO,
Morphine, CBC, BMP
Advance to barium enema.
Change to inpatient unit.
Advance to patient updates.
General, Abdomen
Advance to case end.
Counsel family, Reassure
5—ABDOMINAL PAIN
43
Case #14
Location: Emergency Department
Chief Complaint: Abdominal pain and constipation
Case
introduction
Initial vital signs
Initial history
•A 74-year-old white woman is brought to the emergency department from her
nursing home for worsening abdominal pain and constipation over the past 3 days.
•Unremarkable
•The patient is brought to the emergency department by ambulance with her nurse,
who describes increasing abdominal discomfort over the past 3 days. The patient
lives in a nursing home and is bedridden. She has a history of stroke and has
aphasia. Her nurse also reports lack of bowel movement for the past 3 days. She
has vomited twice with bilious vomit before arrival. There is no history of fever.
•Past medical history includes hypertension, multiple strokes, and arthritis.
•Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Patient appears uncomfortable and fidgeting in bed.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds high pitched and hyperactive. Abdominal fullness and tenderness.
Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Neuro/Psych
Patient aphasic and bedridden. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
44
II—CCS CASES BY CHIEF COMPLAINT
Case #14: Sigmoid Volvulus
Keys to Diagnosis
n
n
n
Look for an adult older than 60 years with the classic triad of abdominal pain, abdominal
­distention, and constipation.
Examination shows abdominal distention and tenderness with either hyperactive or
­decreased bowel sounds.
Abdominal X-ray is diagnostic in most cases.
Management
n
n
n
A volvulus should be reduced. Options for reduction include sigmoidoscopy, anoscopy, ­rectal
tube, and barium enema.
CBC, PT/PTT, and BMP are optional routine evaluations in this setting.
Surgical consult should be made for consideration of surgical resection because volvulus
­often recurs.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: abdominal
•Abdominal x-ray,
acute series
THERAPY
•Exam: skin, lungs, heart, rectal
•CBC
•BMP
•PT/PTT
•Intravenous access
•Normal saline, 0.9% NaCl
•Morphine for pain
•Promethazine hydrochloride for nausea
•Reassure patient
•Sigmoidoscopy,
flexible (or rectal
tube)
•Consult, general
surgery
•Vital signs as needed
•Emergency department transfer to inpatient unit for observation.
•Diagnosis and management should be instituted within 2 hours of simulated
time.
Exam
General, Heart, Lungs, Abdomen, Rectal ± Others
Orders
Abdominal X-ray, acute series
Clock
Advance to abdominal X-ray.
Orders
Sigmoidoscopy, flexible, Morphine, Promethazine
Clock
Advance to sigmoidoscopy results.
Exam
Abdomen +/- Others
Orders
Consult surgery, Reassure
Location
Change to inpatient unit
Clock
Advance to surgery consult, additional updates and case end.
End Orders
None
MONITORING
LOCATION
TIMING
SEQUENCING
45
5—ABDOMINAL PAIN
Case #15
Location: Emergency Department
Chief Complaint: Abdominal pain with a past history of trauma
Case introduction
Initial vital signs
Initial history
•A 37-year-old white man is brought to the emergency department by his wife
for worsening abdominal pain over the past 2 hours.
•Respiratory rate: 22/min
•The patient describes worsening abdominal pain over the past 2 hours. The
pain is generalized and crampy and occurs at intervals, with severe pain for several minutes followed by several minutes of pain relief. When severe, the pain
is rated 8 on a 10-point scale. The patient tried acetaminophen, which did not
relieve the pain. There is no history of infection, fever, constipation, or diarrhea.
•Past medical history of abdominal surgery for a gunshot wound 3 years ago.
•Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in moderate distress, holding his abdomen.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Abdominal scar from previous surgery. Hyperactive bowel sounds. Moderate
abdominal distention and tenderness. Liver and spleen not palpable. No
hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
46
II—CCS CASES BY CHIEF COMPLAINT
Case #15: Small Bowel Obstruction
Keys to Diagnosis
n
n
n
Abdominal pain is typically crampy and occurs every few minutes. Nausea, vomiting, and
constipation may also be seen. Look for history of prior abdominal surgery or trauma.
Abdominal exam may show distention, tenderness, and hyperactive or diminished bowel
sounds.
Abdominal X-ray is generally diagnostic and shows dilated loops of small bowel with
­multiple air-fluid levels. Abdominal CT is increasingly used because it is better at defining
the site of obstruction and possible cause.
Management
n
n
n
n
n
Surgical consult for repair.
IV access and fluid resuscitation.
Nasogastric tube with enteral decompression to remove gas and fluid proximal to the
­obstruction.
Broad-spectrum antibiotic (Cefoxitin) is typically used if surgical management is planned.
Routine orders: CBC, BMP, PT/PTT, pain control, nausea control, type and crossmatch
blood.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: abdomen, rectal
•Abdominal CT (or Abdominal
X-ray, acute series)
•Exam: additional ± complete
•CBC
•BMP
•PT/PTT
•Consult, general surgery
•Intravenous access
•Nasogastric tube
•Morphine
•Normal saline, 0.9% NaCl
•Promethazine hydrochloride
•Cefoxitin
•Type and crossmatch, blood
•Nothing by mouth
•Reassure patient
•Not important in the time frame of this case
•Emergency department
•Diagnosis and management should be instituted within 1 hour of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
General, Heart, Lungs, Abdomen, Rectal ± Others
Abdominal CT (or Abdominal X-ray, acute series)
Advance to imaging results.
Intravenous access, Normal saline, Consult general surgery,
Nasogastric tube, Nothing by mouth, CBC, BMP, PT/PTT,
Meperidine, Metoclopramide, Cefoxitin, Type and crossmatch
blood, Reassure patient
Advance to surgery consult and case end.
None
47
5—ABDOMINAL PAIN
Case #16
Location: Office
Chief Complaint: Abdominal pain and flank pain
Case introduction
Initial vital signs
Initial history
•A 42-year-old white man presents to the office with a 2-month history of abdominal pain, flank pain, and fatigue.
•Blood pressure, systolic: 160 mm Hg
•Blood pressure, diastolic: 100 mm Hg
•The patient has had intermittent lower abdominal and flank pain for the past 2
months. The pain is described as a dull ache. Ibuprofen sometimes relieves the
pain, which is rated 4 on a 10-point scale. He has occasional episodes of light
brown-colored urine and occasionally gets generalized headaches. There is no
history of fever, night sweats, constipation, or diarrhea.
•Past medical history of urinary tract infection treated 1 month ago.
•Family history includes a father who died of kidney failure at age 62 years.
•Social history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. Bilateral masses palpable. Liver and spleen
not palpable. No hernias.
Genitalia
Normal circumcised penis; normal scrotum; testes without masses. No inguinal
hernia.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal. Bilateral flank masses present.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
48
II—CCS CASES BY CHIEF COMPLAINT
Case #16: Adult Polycystic Kidney Disease
Keys to Diagnosis
n
n
n
Common symptoms include pain (abdominal or flank), fatigue, weakness, hypertension,
headache, nocturia, and hematuria. Look for family history of renal failure. Vital signs may
show hypertension.
Exam may show abdominal or flank mass.
Abdominal ultrasound or CT confirms the diagnosis. Evaluate for anemia, electrolyte
­abnormalities, renal failure, UTI and hyperlipidemia.
Management
n
n
n
n
n
Control blood pressure with an ACE inhibitor and a low-sodium diet.
Treat any renal failure, electrolyte abnormality, hematuria, or UTI (e.g., ciprofloxacin).
Consider MRA brain to evaluate for intracranial aneurysms if the patient is in a high-risk job
or there is family history of stroke.
Reduce pain (avoid NSAIDs, treat pain with surgical drainage of cyst).
Nephrology and/or surgical consult is generally recommended, along with genetics consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: abdomen, back
•Abdominal ultrasound or CT
•CBC
•BMP
•Urinalysis
•Lisinopril
•Diet low sodium
•Exam: complete
•Urine culture
•Urine cytology
•Uric acid
•Lipid profile
•Consult, nephrology
•Consult, general surgery
•Diet low protein
•Advise patient, no contact sports
•Reassure patient
•Not important for the time frame of this case
•Most cases can be managed as outpatients in the office.
•Admit if septic or severe pain.
•Diagnosis and management should be instituted within 3 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Abdominal, Extremities, Heart, Lungs ± Others
Abdominal ultrasound
Advance clock 30 min to abdominal ultrasound results.
CBC, BMP, Lipid profile, Urinalysis, Urine culture, Urine cytology,
Lisinopril, Diet low sodium, Diet low protein, Advise no contact
sports, Counsel, Reassure. Consider MRA brain if patient meets
criteria.
Reschedule patient after results are reported.
Consult general surgery, Consult nephrology, Consult genetics, Treat
any complications (UTI, renal failure, hyperkalemia)
Advance to additonal results, updates and case end
None
49
5—ABDOMINAL PAIN
Case #17
Location: Office
Chief Complaint: Abdominal discomfort and distention
Case introduction
Initial vital signs
Initial history
•A 47-year-old African-American woman presents to the office with a 1-month
history of increasing abdominal discomfort and distention.
•Unremarkable
•The patient reports increasing abdominal distention and discomfort over the
past month. The abdominal fullness has caused increased urinary frequency,
nocturia, reflux, and belching. She has occasional episodes of shortness of
breath. There is no change in appetite or diet. There is no history of fever,
constipation, or diarrhea.
•Past medical history of three childbirths with normal vaginal deliveries.
•Patient has smoked two packs of cigarettes a day for the past 20 years. No
history of significant alcohol or illicit drug use.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Breasts
Nipples normal; no masses.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Mild dullness to percussion and reduced breath sounds at bases.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bowel sounds normal; no bruits. Abdominal fullness and tenderness with shifting
dullness. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. Left adnexal
mass.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
50
II—CCS CASES BY CHIEF COMPLAINT
Case #17: Ovarian Cancer
Keys to Diagnosis
n
n
n
Common symptoms include abdominal fullness, distention, and discomfort with associated
symptoms—urinary frequency, constipation, indigestion, reflux, and shortness of breath,
tiredness, and weight loss.
Exam may show pelvic or adnexal mass, ascites, or signs of pleural effusion.
Abdominal/pelvic ultrasound is the most useful initial study. Tumor markers include
­CA-125, hCG, and alpha-fetoprotein. Screen with mammography and chest X-ray.
Management
n
n
n
Surgical consult or laparoscopy.
Medical Oncology consult for possible chemotherapy (for stage II or greater).
Counseling and reassurance.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: abdomen, genitalia
•Pelvic ultrasound
•Paracentesis
•Ascitic fluid cytology
•CA-125, serum
THERAPY
•Mammogram
•Chest x-ray (CXR) PA/Lateral
•Pap smear
•Alpha-fetoprotein, serum
•HCG, beta, serum, quantitative
•CBC
•BMP
•Consult hematology/oncology
•Advise patient, no smoking
•Advise patient cancer diagnosis
•Consult general surgery
•Reassure patient
•None
•Office to inpatient unit for management of ascites
•Diagnosis and management should be instituted within 2 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Location
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Heart, Lungs, Abdomen, Genitalia ± Others
Change to inpatient unit.
Chest X-ray, PA/lateral, Pelvic ultrasound
Advance clock to results.
Paracentesis, Ascitic fluid cytology, CA-125 serum, Alphafetoprotein serum, HCG beta serum quantitative, CBC, BMP
Advance clock to results of cytology.
Consult general surgery, Advise patient cancer diagnosis, Consult
hematology/oncology, Reassure patient
Advance to surgical consult and case end.
None
51
5—ABDOMINAL PAIN
Case #18
Location: Emergency Department
Chief Complaint: Abdominal pain and vaginal discharge
Case introduction
Initial vital signs
Initial history
•A 22-year-old white woman is brought to the emergency department by her
sister for increasing lower abdominal pain over the past 2 days.
•Temperature: 38.3 degrees C (101.0 degrees F)
•The patient has had fever and chills for 2 days with abdominal pain that began
as a dull ache and now is generalized and moderate in severity, rated as a 6 on
a 10-point scale. Several hours ago, she had onset of a foul-smelling vaginal
discharge with nausea and one episode of vomiting. She has had two episodes
of painful intercourse over the past week. Her last menstrual period was 3
weeks ago. She has three male sexual partners and occasionally uses condoms for contraception. She drinks alcohol on weekends and has no history of
smoking or illicit drug use.
•Past medical history of treatment for gonorrhea 4 months ago and chlamydia 2
years ago. She was treated for a urinary tract infection 8 months ago. She had
a normal Pap smear result 4 months ago.
•Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Breasts
Nipples normal; no masses.
Lymph nodes
Mildly enlarged inguinal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. Bilateral lower abdominal tenderness. Liver
and spleen not palpable. No hernias.
Genitalia
Normal labia. Mucopurulent vaginal discharge present. Cervical motion
tenderness present. Uterus not enlarged. Bilateral adnexal tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
52
II—CCS CASES BY CHIEF COMPLAINT
Case #18: Pelvic Inflammatory Disease
Keys to Diagnosis
n
n
n
Look for a young woman with abdominal/pelvic pain, vaginal discharge, dysuria, and pain or
bleeding with intercourse. History may show multiple sexual partners, prior STI, or lack of
condom use. Vital signs show a fever.
Examination shows purulent vaginal discharge, adnexal tenderness, or cervical motion tenderness.
Order hCG to rule out pregnancy. Abdominal or transvaginal ultrasound may show fallopian
tube dilation or abnormalities in the ovaries. MRI has higher sensitivity than ultrasound
but is more costly. Order studies for sexually transmitted diseases: chlamydia, gonorrhea, Trichomonas, HIV, hepatitis.
Management
n
n
n
Decide whether to admit: tubo-ovarian abscess, pregnant, immunodeficient, severe illness,
noncompliant.
Antibiotic treatment should be effective against gonorrhea and chlamydia + anerobes.
If inpatient, use cefotetan IV or cefoxitin IV + doxycycline oral. Stop IV meds 24 hours after
improvement, but continue Doxycycline for 14 days. If tubo-ovaian abscess present, add
Metronidazole, oral for 14 days. If outpatient treatment, use ceftriaxone IM single dose +
doxycycline oral for 14 days + metronidazole oral for 14 days.
Counseling to avoid sex, use safe sex techniques, and treat partners if needed.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•hCG, beta, urine qualitative
•CBC
•Transvaginal ultrasound
•BMP
•Vaginal pH
•Urinalysis
•Vaginal secretion, wet mount
•Urine culture
•Vaginal KOH prep
•Hepatitis B surface antigen, serum
•Cervical DNA, gonorrhea
•Hepatitis C antibody, serum
•Cervical DNA, chlamydia
•HIV antibody test, rapid, blood
•Intravenous access
•PT/PTT
•Cefotetan, IV
•NSAID or morphine
•Doxycycline, oral
•Advise patient, safe sex
•Consult, general surgery
•Advise patient, treat partner
•Monitor vital signs if needed.
•Emergency department to inpatient unit if patient meets criteria and needs
parenteral antibiotic therapy or possible surgery.
•Outpatient therapy if patient stable and compliant.
•Diagnosis and management should be instituted within 4 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
Orders
Clock
End Orders
General, Skin, Heart, Lungs, Abdomen, Genitalia, Rectal ± Others
hCG urine, qualitative
Advance to hCG results.
Transvaginal ultrasound, Vaginal pH, Vaginal wet mount, Vaginal KOH
prep, Cervical DNA, gonorrhea, Cervical DNA, chlamydia, HIV rapid
test, Urinalysis, Urine culture
Advance to transvaginal ultrasound results.
Antibiotics (Cefotetan, Doxycycline or see above), Consult surgery,
CBC, BMP, Hepatitis B surface antigen, Hepatitis C antibody
Change to inpatient unit (if patient meets criteria).
Advance to additional results.
Advise patient: avoid sex, safe sex techniques, treat partners
Advance to patient updates and case end
None
53
5—ABDOMINAL PAIN
Case #19
Location: Emergency Department
Chief Complaint: Severe epigastric pain
Case introduction
Initial vital signs
Initial history
•A 46-year-old man is brought to the emergency department by his wife 45
minutes after onset of severe epigastric pain.
•Pulse: 126 beats/min
•Respiratory rate: 26/min
•Blood pressure, systolic: 104 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient experienced sudden onset of severe epigastric pain 45 minutes
ago while he was resting at home. The pain is constant and rated 10 on a
10-point scale. The pain radiates to the left shoulder. Changing body position
does not relieve the pain. In addition, he has been feeling increased fatigue over
the past 2 months. He has had heartburn over several years treated with antacids, which appears to have been worsening over the past 2 months. There is
no shortness of breath, constipation, or diarrhea.
•Past medical history includes heartburn treated with over-the-counter antacids
and a motor vehicle accident 4 years ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, mildly overweight. Moaning, lying immobile, holding his stomach
in distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
Tachycardic. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Cardiovascular
Central and peripheral pulses weak. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds absent; no bruits. Abdomen diffusely tender and rigid. No
hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult blood
positive.
What is the suspected diagnosis, and what are the next steps in management?
54
II—CCS CASES BY CHIEF COMPLAINT
Case #19: Peptic Ulcer Disease with Perforation
Keys to Diagnosis
n
n
n
For peptic ulcer disease, look for epigastric pain that is gnawing or burning, occurring after
meals, and that may be relieved by foods or antacids. Other symptoms include belching,
bloating, heartburn, melena, fatigue from anemia, and weight loss. In patients with perforation, look for more severe, sharp abdominal pain with abnormal vital signs.
On exam, peptic ulcer disease may show mild tenderness. If perforated, abdominal rebound
tenderness, guarding, and rigidity are present. Stool occult blood positive.
Endoscopy is the diagnostic test of choice in peptic ulcer disease, however should not be used
if perforation suspected. A chest X-ray may show free abdominal air in perforation. Abdominal
CT scan is typically used as the primary diagnostic modality in perforation. Baseline testing
for CBC, BMP, type and crossmatch, PT/PTT, LFT, amylase, and lipase is recommended.
Testing for H. pylori is generally performed.
Management
n
n
For nonperforated ulcers: treat H. pylori (PPI + two antibiotics; e.g., omeprazole + clarithromycin + amoxicillin); avoid NSAIDs, alcohol, and smoking.
For perforation and an unstable patient: IV access and normal saline, ABCs (intubation
if needed), nasogastric tube suction, urgent surgical consult, IV proton pump inhibitor (e.g., Pantoprazole sodium), IV antibiotics (e.g., metronidazole + gentamicin) and eventual
treatment of H. pylori.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Abdominal X-ray, acute series
•Abdominal CT
•CBC
•PT/PTT
THERAPY
•ECG, 12-lead
•Troponin I
•BMP
•LFT
•Amylase, serum
•Lipase, serum
•Intravenous access
•Normal saline solution, 0.9% NaCl
•Nothing by mouth
•Nasogastric tube
•Foley catheter
•Morphine, IV
•Consult, Surgery
•Type and crossmatch, blood
•Pantoprazole sodium, IV
•Metronidazole, IV
•Gentamicin, IV
•Blood pressure monitor, continuous
•Pulse oximetry
•Cardiac monitor
•For perforation, initial management in the ED with surgical referral.
•Diagnosis and management should be instituted within 2 hours of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor, Pulse oximetry, Cardiac monitor
General, Chest, Heart, Abdomen, Rectal ± Others
Abdominal X-ray, acute series, Morphine, IV access, Normal saline
Advance to abdominal X-ray.
Abdominal CT scan, CBC, PT/PTT, BMP, LFT, Amylase, Lipase,
ECG, Troponin
Advance to abdominal CT.
Consult surgery, Pantoprazole sodium, Metronidazole, Gentamicin,
Type and crossmatch, blood, Nasogastric tube, Foley catheter
Advance to surgical consult and case end.
Urea breath test
55
5—ABDOMINAL PAIN
Case #20
Location: Emergency Department
Chief Complaint: Abdominal pain in the left upper quadrant
Case introduction
Initial vital signs
Initial history
•A 22-year-old white man returns to the emergency department for worsening
abdominal pain 1 day after leaving against medical advice.
•Respiratory rate: 23/min
•Blood pressure, systolic: 110 mm Hg
•Blood pressure, diastolic: 70 mm Hg
•The patient returns to the emergency department with worsening abdominal
pain 1 day after leaving against medical advice. He was assaulted outside a
bar yesterday after a night of heavy drinking and left the emergency department before completion of evaluation. The abdominal pain is a dull, constant
ache located in the left upper quadrant, rated as an 8 on a 10-point scale.
Acetaminophen provides only minor relief of the pain.
•Past medical history is unremarkable.
•He smokes one pack of cigarettes a day for the past 3 years and drinks 8 to
10 beers on weekends.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in moderate distress.
HEENT/Neck
Bruises on the side of the head. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Abdomen
Several abdominal bruises. Bowel sounds normal; no bruits. Left upper quadrant
tender to palpation. No hernias.
Extremities/Spine
Multiple bruises and healing superficial scrapes on the arms, legs, and back. No
edema. Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
56
II—CCS CASES BY CHIEF COMPLAINT
Case #20: Splenic Hematoma
Keys to Diagnosis
n
n
n
Look for young patient with recent history of trauma presenting with abdominal pain in the
left upper quadrant.
Examination may show left upper quadrant tenderness and other signs of trauma.
A FAST ultrasound may be ordered initially to rule out peritoneal bleed. Abdominal CT
is test of choice for evaluating the spleen and may show hematoma, fluid accumulation, or
rupture. A CBC should be ordered to evaluate for significant blood loss. Baseline labs: BMP,
PT/PTT, troponin, LFT, amylase, urinalysis.
Management
n
n
n
Most patients can be managed conservatively if they have stable vital signs, stable ­hemoglobin,
and low-grade injury on CT and are younger than 55 years.
Admit to ICU if hemodynamically unstable or if >3 cm splenic laceration or >50% subcapsular hematoma.
Surgical consult should be routinely obtained. Type and crossmatch, blood for potential
transfusions.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: heart, lungs, abdomen,
extremities
•FAST ultrasound
•Abdominal CT scan
•CBC
•Exam: additional
•PT/PTT
•BMP
•Troponin
•Amylase
•LFT
•Urinalysis
•Normal saline, 0.9% NaCl
•Intravenous access
•Morphine
•Oxygen
•Consult, general surgery
•Advise patient, no smoking
•Type and crossmatch, blood
•Advise patient, limit alcohol intake
•Blood pressure monitor
•CBC daily
•Pulse oximetry
•Abdominal CT scan follow-up
•If patient not taken to surgery, admit to inpatient unit or ICU, depending on
severity.
•Diagnosis and management should be instituted within 2 hours of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Clock
Orders
Clock
End Orders
Blood pressure monitor, Pulse oximetry
General, Heart, Lungs, Abdomen
FAST Ultrasound, Morphine, Normal saline
Advance to ultrasound result.
Abdominal CT scan, CBC, BMP, PT/PTT, Troponin, Amylase, LFT,
Urinalysis, Type and crossmatch, blood
Advance to Abdominal CT scan result.
Consult, general surgery
Advance to consult
Change to inpatient unit or ICU depending on severity.
Advance to additional results and patient updates.
Advise patient no smoking, Advise patient limit alcohol
Advance to additional updates and case end.
CBC, Abdominal CT scan as follow-up.
57
5—ABDOMINAL PAIN
Case #21
Location: Office
Chief Complaint: Abdominal discomfort and malaise
Case introduction
Initial vital signs
Initial history
•A 39-year-old African-American man presents to the office with a 3-week history of abdominal discomfort and malaise.
•Temperature: 38.0 degrees C (100.4 degrees F)
•Blood pressure, systolic: 116 mm Hg
•Blood pressure, diastolic: 72 mm Hg
•The patient describes abdominal discomfort that is predominantly in the
left lower quadrant and is crampy. The pain is partially relieved with bowel
movements and is rated 5 on a 10-point scale. He has had mild nausea and
vomited once 2 days ago. He had one episode of shaking chills last night. He
has not had a bowel movement in 2 days. His diet consists mainly of fast-food
meals.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds reduced. Left lower quadrant tenderness with guarding. Liver
and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; Occult blood
positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
58
II—CCS CASES BY CHIEF COMPLAINT
Case #21: Acute Diverticulitis
Keys to Diagnosis
n
n
n
Look for a patient with abdominal pain, usually in the left lower quadrant, that is crampy
and associated with a change in bowel habits. Other symptoms include nausea, vomiting,
flatulence, and bloating.
Abdominal exam may show mild tenderness in simple diverticulitis, a mass if abscess is present, or rebound tenderness and guarding if peritonitis is present.
The diagnosis is usually based on history and exam. Abdominal CT confirms the diagnosis,
which may also show abscess, fistula formation, and obstruction.
Management
n
n
For uncomplicated diverticulitis: 7 to 10 days of oral antibiotics (e.g., ciprofloxacin +
­metronidazole) plus clear liquid diet.
For complicated patients (severe pain, peritonitis, immunocompromised, comorbidities):
­admit to inpatient unit, NPO, IV fluids, morphine, start IV antibiotics (e.g., monotherapy
with ­piperacillin/tazobactam or combination metronidazole + cefotaxime). Surgical consult
if ­abscess present for drainage.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: abdomen, rectal
•Abdominal CT scan
THERAPY
•Antibiotics (e.g., metronidazole, IV +
cefotaxime, IV)
•Consult, general surgery
•CBC
•Blood culture
•BMP
•LFT
•Urinalysis
•Urine culture
•PT/PTT
•Intravenous access
•Normal saline, 0.9% NaCl
•Nothing by mouth
•Morphine
•Type and screen, blood
MONITORING
•Temperature
•Vital signs
•If patient presents in office, admit to inpatient unit if complicated diverticulitis.
•Diagnosis and management should be instituted within 2 hours of simulated time.
LOCATION
TIMING
SEQUENCING
Exam
Location
Orders
Clock
Orders
Clock
Exam
Orders
Clock
End Orders
Heart, Lungs, Abdomen, Rectal ± Others
Change to inpatient unit
Blood pressure monitor, Abdominal CT scan
Advance to abdominal CT scan results.
Consult general surgery, Intravenous access, Normal saline, Nothing
by mouth, Antibiotics (Metronidazole+ Cefotaxime), CBC, BMP, LFT,
Urinalysis, Urine culture, Blood culture, PT/PTT, Type and screen
blood
Advance to obtain results and patient updates.
Abdomen + Others
Counsel patient, Reassure patient
Advance to additional updates and case end
None
59
5—ABDOMINAL PAIN
Case #22
Location: Emergency Department
Chief Complaint: Generalized abdominal pain
Case introduction
Initial vital signs
Initial history
•A 63-year-old Latino man is brought to the emergency department by ambulance for severe abdominal pain that began 30 minutes ago.
•Temperature: 37.0 degrees C (98.6 degrees F)
•Pulse: 120 beats/min
•Respiratory rate: 34/min
•Blood pressure, systolic: 104 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient woke from an afternoon nap with severe, generalized abdominal
pain that is poorly localized. The pain is constant and not relieved by any
change in position. The pain is rated 10 on a 10-point scale. He experienced
nausea and one episode of vomiting with the pain. He has never experienced
this type of pain before.
•Past medical history of hyperlipidemia and coronary artery disease treated with
medications.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
94% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed man in acute distress, holding his abdomen.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds mildly hyperactive; no bruits. No masses, rebound tenderness
or guarding. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult blood
positive.
What is the suspected diagnosis, and what are the next steps in management?
60
II—CCS CASES BY CHIEF COMPLAINT
Case #22: Mesenteric Ischemia
Keys to Diagnosis
n
n
n
Classic presentation is severe, acute abdominal pain that is poorly localized. Additional
symptoms include nausea, vomiting, and diarrhea.
Abdominal examination is characteristically normal in the face of severe pain. Occult blood
may be present.
Abdominal CT is the test of choice to evaluate for acute ischemia. Abdominal X-ray may be
performed initially to rule out perforation and free air. Serum lactate is usually elevated.
Management
n
n
n
n
ABCs (intubation if needed).
Morphine for pain relief, broad-spectrum antibiotics (e.g., metronidazole + gentamicin).
Nasogastric tube to evaluate for the presence of blood and relieve distention secondary to
ileus.
Surgical consult; type and crossmatch, blood.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Abdomen
•Abdominal X-ray, acute series
•Abdominal CT scan
•Lactate
THERAPY
•CBC
•BMP
•LFT
•Amylase
•Lipase
•Blood culture
•Intravenous access
•Oxygen
•Nasogastric tube
•Foley catheter
•Nothing by mouth
•Normal saline solution, 0.9% NaCl
•Morphine, IV
•Consult, surgery, general
•Type and crossmatch, blood
•Gentamicin, IV
•Metronidazole, IV
•Blood pressure monitor, continuous
•Pulse oximetry
•Cardiac monitor
•Initial management in emergency department with subsequent transfer to
surgery, ICU, or inpatient unit depending on the case.
•Diagnosis and management should be instituted within 2 hours of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor, Pulse oximetry, Cardiac monitor
General, Chest, Heart, Abdomen, Rectal
Abdominal X-ray, acute series, Morphine, Intravenous access,
Normal saline
Advance to X-ray results.
Abdominal CT scan, CBC, BMP, LFT, Amylase, Lipase, Blood
culture, Urinalysis
Advance to CT scan results.
Consult, surgery, Type and crossmatch, blood, Nothing by mouth,
Gentamicin, Metronidazole, Nasogastric tube, Foley catheter
Advance to surgical consult, additional results, and case end.
None
5—ABDOMINAL PAIN
61
Abdominal Pain—Key Points
n
n
n
n
bdominal pain is commonly tested on the CCS. Expect one or more CCS cases of a
A
patient presenting with abdominal pain.
In most cases, the diagnosis should be evident from the history and initial examination.
Additional diagnostic studies should confirm the suspected diagnosis and rule out other
diagnoses.
Some general rules to follow in patients with abdominal pain:
n If vital signs are abnormal, begin with monitoring orders.
n If the patient is in acute distress, perform only a limited physical exam.
n If the patient is a reproductive-age woman, check urine hCG and avoid CT for ultrasound if possible.
n If the patient is in severe pain, order pain relief early.
n Do not order surgical consult too early. A surgical consult may not do anything if you
order that up front but may take the patient to surgery after you have confirmed the
diagnosis.
In patients who present acutely, when the clock is advanced, patient update screens will
happen fairly quickly to help you determine whether you are managing the patient correctly.
If you get a negative update on a patient, reevaluate whether your suspected diagnosis is
correct.
C H A P T E R
6
Fatigue
Key Orders*
Order
CCS Terminology
Pregnancy test, urine,
qualitative
hCG, beta, urine, qualitative
Depression index
ECG, 12-lead
Depression index
Electrocardiography, 12-lead
HIV antibody test, rapid, blood
Urinalysis
Antibody, rapid HIV test, blood
Urinalysis
BMP
Basic metabolic profile
Fasting blood glucose
CBC with differential
Glucose, serum, fasting
CBC with differential
Colonoscopy
Colonoscopy
EGD
Endoscopy, upper gastrointestinal
Pancreatic needle biopsy
LFT
Phosphate, serum
Bone marrow aspiration
Bone marrow biopsy, needle
Magnesium, serum
Abdominal CT with contrast
Biopsy, pancreas, needle
Liver function panel
Phosphorus, serum
Aspirate, bone marrow
Biopsy, bone marrow, needle
Magnesium, serum
CT, abdomen/pelvis, with contrast
Hemoglobin A1c, blood
Urine, microalbumin
Lipid profile
Urine cytology
H. pylori urea breath test
HIV test, ELISA, serum
Ferritin, serum
Iron, serum w/TIBC
Lead, blood, quantitative
B12, serum
Folate, serum
TSH, serum
Free T4
CA 19-9, serum
Hemoglobin A1c, blood
Microalbumin, urine
Lipid profile
Cytology, urine
Urea breath test
Antibody, HIV, ELISA, serum
Ferritin, serum
Iron and total iron-binding capacity, serum
Lead, blood, quantitative
Vitamin B12, serum
Folic acid, serum
Hormone, thyroid stimulating, serum
Thyroxine, serum, free
CA 19-9, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—­
Office Setting
5 min (stat),
20 min (routine)
10 min
15 min (stat),
30 min (routine)
20 min
30 min (stat),
6 hr (routine)
30 min (stat),
2.5 hr (routine)
1 hr
1 hr (stat),
24 hr (routine)
1 hr (stat),
25 hr (routine)
1 hr (stat),
25 hr (routine)
1 hr
2.5 hr
3 hr
3 hr
3 hr
4 hr
4 hr (stat)
24 hr (routine)
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
2 days
2 days
3 days
63
6—FATIGUE
Case #23
Location: Office
Chief Complaint: Fatigue and constipation
Case introduction
Initial vital signs
Initial history
•A 56-year-old white man presents to the office with a 3-month history
of fatigue and intermittent constipation.
•Unremarkable.
•The patient has had increasing fatigue over the past 3 months. He has
difficulty exercising and running around his block, which was not a
problem last year. He has had a 10-lb weight loss despite no change in
appetite or diet. He has intermittent episodes of constipation associated with mild abdominal pain for 2 to 3 days at a time.
•Past medical history unremarkable.
•He has smoked one pack of cigarettes a day for the past 30 years.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
­Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Pale appearance. Normal turgor. No nodules or other lesions. Hair and nails
normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Mouth shows pale conjunctivae.
Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal circumcised penis; normal scrotum; testes without masses. No
inguinal hernia.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult blood
positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
64
II—CCS CASES BY CHIEF COMPLAINT
Case #23: Colon Cancer/Iron Deficiency Anemia
Keys to Diagnosis
n
n
n
The presentation is often vague and nonspecific: fatigue, malaise, anorexia, weight loss, and
change in bowel habits. Some more specific signs include dull abdominal pain, rectal bleeding, and obstruction.
On exam, look for occult blood positive on rectal exam.
Diagnosis is based on colonoscopy. Order a CBC and iron studies looking for iron deficiency
anemia. Additional causes of fatigue (diabetes, thyroid dysfunction, electrolyte abnormalities) should be ruled out. Additional studies include CEA and LFT for hepatic metastasis.
Management
n
n
n
Treatment can include surgery, chemotherapy, and radiation, depending on the stage. If time
permits, order staging studies.
Treat iron deficiency anemia with iron supplementation.
Counseling and reassurance. Advise advance directive if high-stage tumor.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: rectal, HEENT, Lymph
nodes
•CBC
•Ferritin
•CEA
•Colonoscopy
THERAPY
•Exam: Additional ± Complete
•BMP
•TSH
•Glucose fasting
•LFT
•Urinalysis
•Iron and TIBC
•Abdominal CT scan
•Chest CT
•Bone scan
•ECG
•Consult, hematology/oncology
•Consult, radiation therapy
•Reassure patient
•Advise patient, advance directive (if
metastatic)
•Advise patient, no smoking
•Advise patient, cancer
diagnosis
•Colectomy or Consult, general
surgery
•Iron sulfate, oral
•CBC, CEA, and ferritin should be monitored after treatment initiated.
•Unless there is severe anemia requiring transfusion, treatment can be done
as an outpatient.
•Diagnosis and management should be instituted within 4 days of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Rectal, HEENT, Heart, Abdomen, Lymph nodes ± Others
CBC, BMP, TSH, Glucose fasting, LFT, Urinalysis,
Colonoscopy, Advise patient no smoking
Advance clock to reschedule patient when all results are
reported.
Ferritin, Iron and TIBC, CEA, Abdominal CT scan, Chest CT
scan, Advise patient cancer diagnosis, Reassure patient
Advance clock to reschedule patient when all results are
reported.
Consult, general surgery (or Colectomy), Iron sulfate, Consult,
hematology/oncology, Consult, radiation therapy
Advance to case end.
CBC, CEA, Ferritin in 1 month
65
6—FATIGUE
Case #24
Location: Office
Chief Complaint: Fatigue and weight gain
Case introduction
Initial vital signs
Initial history
•A 47-year-old African American woman presents to the office with fatigue and
constipation for 5 months.
•Pulse: 68 beats/min
•Height: 162.6 cm (64.0 in)
•Weight: 78.6 kg (173.3 lb)
•Body mass index: 29.7 kg/m2
•The patient presents with fatigue, lethargy, and weakness over the past 5
months. She notes increasing tiredness performing activities, such as going
to work, which she previously did not have difficulties with. She also has had
intermittent constipation and weight gain of about 20 lb despite no change in
appetite.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, overweight; in no apparent distress.
Skin
Dry, coarse skin. No nodules or other lesions. Hair brittle.
Breasts
Nipples normal; no masses.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Loss of lateral third of eyebrows. Funduscopic
examination normal. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
delayed.
What is the suspected diagnosis, and what are the next steps in management?
66
II—CCS CASES BY CHIEF COMPLAINT
Case #24: Hypothyroidism
Keys to Diagnosis
n
n
n
n
ypical symptoms include fatigue, lethargy, weakness, constipation, weight gain, cold intolT
erance, memory loss, and muscle weakness.
Vitals may show bradycardia, and weight gain. On exam, look for dry, coarse skin; brittle
hair; loss of outer eyebrows; thick tongue; enlarged thyroid gland; delayed deep tendon reflexes; and muscle weakness.
Diagnosis based on high TSH, decreased free T4. Other labs commonly abnormal to check:
CBC (anemia), lipid profile (hyperlipidemia), and BMP (hyponatremia).
Rule out other causes of fatigue, such as diabetes and depression. For young women, check
urine hCG.
Management
n
n
evothyroxine oral for initial therapy. Monitor TSH every 6 to 8 weeks.
L
Counseling regarding diet, exercise, and medication compliance.
DIAGNOSIS
THERAPY
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam
•TSH, serum
•Thyroid hormone, free T4
•CBC
•BMP
•Lipid profile
•Levothyroxine sodium, oral
•Advise patient, exercise program
•Diet, high fiber
•Diet, low fat
•LFT
•Glucose, serum, fasting
•ECG, 12-lead
•Urinalysis
•Depression index
•Advise patient, medication
compliance
•Advise patient, side effects of
medication
•Reassure patient
MONITORING
LOCATION
TIMING
•TSH every 6–8 weeks
•Most patients can be managed as outpatients.
•Diagnosis and management should be instituted within 4 days of simulated
time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Skin, HEENT, Heart, Lungs, Abdomen, Rectal ± Complete
CBC, BMP, TSH, Free T4, Lipid profile, Glucose fasting,
Urinalysis, LFT, ECG, Depression index
Advance clock to reschedule patient when all results are
reported.
Levothyroxine, Diet high fiber, Diet low fat, Advise patient
medication compliance, Advise patient side effects of
medication, Advise patient exercise program, Reassure
patient
Advance clock to reschedule patient in 6 weeks and case
end.
TSH in 6 weeks
67
6—FATIGUE
Case #25
Location: Office
Chief Complaint: Fatigue
Case introduction
Initial vital signs
Initial history
•A 49-year-old Latina woman presents to the office with a 4-month history of
fatigue.
•Height: 167 cm (65.7 in)
•Weight: 91.0 kg (200.1 lb)
•Body mass index: 32.6 kg/m2
•The patient has had increasing fatigue and tiredness over the past 4 months.
She notes difficulty with her normal activities, such as walking her dog. She
has not had any significant changes in weight. She has not had any fever, night
sweats, constipation, diarrhea, shortness of breath, or chest pain.
•Past medical history includes three urinary tract infections treated 3 months
ago, 6 months ago, and 2 years ago.
•Social history includes smoking one pack of cigarettes a day for the past 25
years. She drinks two to three alcoholic drinks a day. There is no history of illicit
drug use.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
­Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, obese woman; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Funduscopic examination shows microaneurysms
and dot hemorrhages. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve and motor examinations normal.
Sensory examination shows decreased sensation in both feet. Cerebellar
function normal. Deep tendon reflexes delayed.
What is the suspected diagnosis, and what are the next steps in management?
68
II—CCS CASES BY CHIEF COMPLAINT
Case #25: Diabetes Mellitus
Keys to Diagnosis
n
n
n
n
Although the classic symptoms of diabetes mellitus are polydipsia and polyuria, on the CCS,
look for an unusual, nonspecific presentation, such as fatigue, recurrent urinary tract infection, foot infection/osteomyelitis, or vaginal candidiasis. Additional symptoms to look for
include changes in vision, diarrhea, impotence, and urinary hesitancy.
On exam, look for abnormalities on funduscopic exam (microaneurysms, capillary dilatation,
hemorrhages, AV shunts) and neurologic exam (neuropathy with decreased sensation or delayed deep tendon reflexes).
Diagnosis can be made with fasting glucose (repeated on different day), nonfasting glucose if
symptoms present, 75-g glucose tolerance test, or hemoglobin A1c ≥6.5%
Also check lipid profile, urinary protein, and renal function, as well as other causes of fatigue.
Management
n
n
n
n
Lifestyle modifications: diet, exercise, smoking, alcohol.
Metformin may be started on diagnosis (ADA recommendation) or after a trial of lifestyle
modification.
Treat hypertension with ACE inhibitor; treat hyperlipidemia.
Counseling and vaccinations.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: HEENT, Heart, Rectal
•BMP
•Glucose, serum, fasting
•Lipid profile
•Hemoglobin A1c
•Urine microalbumin
THERAPY
•Exam: Complete
•CBC
•Urinalysis
•Depression index
•TSH
•LFT
•ECG
•Aspirin
•Consult, dietary
•Consult, ophthalmology
•Consult, podiatry
•Vaccine, influenza
•Vaccine, pneumococcal
•Advise patient, side effects of medication
•Advise patient, medication compliance
•Diet, low fat
•Advise exercise program
•Diet, diabetic
•Diabetic teaching
•Advise, no smoking
•Advise, limit alcohol
•Metformin hydrochloride, oral
•Lisinopril (if hypertension)
•Hemoglobin A1c every 3 months
•Most patients can be managed as outpatients.
•Diagnosis and management should be instituted within 3 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
CBC, BMP, TSH, Glucose fasting, Urinalysis, LFT, Lipid profile,
Depression index, Diet low fat, Diet calorie restricted, Advise
patient exercise program
Advance clock to reschedule patient when all results are reported.
Glucose fasting (repeat), Hemoglobin A1c, Urine microalbumin
Advance clock to reschedule patient when all results are reported.
Metformin (consider aspirin, lisinopril), Consult ophthalmology,
Consult dietary, Consult podiatry, Diet diabetic, Vaccine influenza,
Vaccine pneumococcal, Diabetic teaching, Advise patient side
effects of medication, Advise patient medication compliance
Advance clock to reschedule patient in 3 months and case end.
Hemoglobin A1c in three months
69
6—FATIGUE
Case #26
Location: Office
Chief Complaint: Fatigue and irritability
Case introduction
Initial vital signs
Initial history
•A 13-month-old white boy is brought to the office by his mother for a
2-month history of fatigue and irritability.
•Unremarkable.
•The mother reports the child has been increasingly irritable and fatigued
over the past 2 months. The child has also appeared pale over the past
few days. He sleeps more than usual and gets tired playing faster than
usual. He is a very fussy eater, drinking mainly cow’s milk and refusing any
vegetables, fruits, and meats. The family lives in a house built in the 1970s
that is in need of repairs, and the mother has found the child eating paint
chips from the wall. There is no history of fever, constipation, or diarrhea.
•Developmental history shows normal milestones obtained.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
­Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed child playing in no apparent distress.
Skin
Pale skin. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth normal.
Pharynx normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal.
Abdomen
Bowel sounds normal. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Genitalia
Normal external genitalia.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Alert; neurologic findings normal.
What is the suspected diagnosis, and what are the next steps in management?
70
II—CCS CASES BY CHIEF COMPLAINT
Case #26: Lead Poisoning/Iron Deficiency Anemia
Keys to Diagnosis
n
n
n
ommon symptoms of lead poisoning include fatigue, irritability, myalgia, headache, conC
stipation, abdominal cramping, and motor neuropathy. Look for a child who lives in an old
house, eating paint chips (or other forms of pica) with a poor diet. For iron deficiency anemia,
look for a child with a poor diet that only drink’s cow’s milk and refuses vegetables and meat.
Examination may show paleness caused by anemia, but results are often normal.
Diagnosis is based on CBC, venous lead level, and iron studies, including ferritin. Case may
either one or both lead toxicity and iron deficiency.
Management
n
n
n
I f lead levels are elevated, consult lead abatement agency and social worker.
If lead >45 µg/dL, order succimer oral. If severe lead toxicity (>70 µg/dL), hospitalize and
order ethylenediaminetetraacetic acid (EDTA) or dimercaprol.
For iron deficiency, order iron replacement, diet recommendations, and dietary consult.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam: Skin
•CBC
•Ferritin
•Lead, blood quantitative
•Iron sulfate
•Lead chelation (Succimer or other
depending on lead level)
•Consult, dietary
•Lead abatement agency
•Exam: Additional
•Reticulocyte count
•Iron and TIBC
•Diet, high iron
•Iron-enriched infant formula
•Advise patient/family, limit intake of
cow’s milk
•Reassure patient/family
•Counsel patient/family
•CBC
•Lead, blood quantitative
•Ferritin
•Office
•Diagnosis and management should be instituted within 4 days of simulated
time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
CBC (stat)
Advance clock with next available result to results of CBC.
Ferritin, Iron and TIBC, Lead blood, Reticulocyte count
Advance clock to reschedule patient when all results are
reported.
Iron sulfate, Lead chelation—succimer (if lead level > 45),
Iron-enriched infant formula, Lead abatement agency, Diet
high iron, Advise patient/family limit intake of cow’s milk,
Reassure patient/family, Consult dietary
Reschedule patient depending on elevated lead levels
(2 days if >50 µg/dL).
Lead, blood
Advance clock to any additional updates and case end
CBC, Lead blood, Ferritin in one month.
71
6—FATIGUE
Case #27
Location: Office
Chief Complaint: Fatigue and jaundice
Case introduction
Initial vital signs
Initial history
•A 69-year-old African American man presents to the office with a 2-month
history of fatigue.
•Unremarkable.
•The patient reports increasing fatigue and difficulty concentrating over the
past 2 months. He has occasional episodes of upper abdominal pain,
which are mild to moderate in severity. He has had a decreasing appetite
and has had a 20-lb weight loss over the time period. He notes his urine is
sometimes very dark and his bowel movements are greasy, with increased
flatulence.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin man in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes show mild scleral icterus. Funduscopic
examination normal. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
72
II—CCS CASES BY CHIEF COMPLAINT
Case #27: Pancreatic Cancer
Keys to Diagnosis
n
n
n
ommon symptoms include jaundice, dull abdominal pain, weight loss, anorexia, greasy
C
stools, dark urine.
Examination may show icterus or ascites but is generally unremarkable.
Diagnosis is based on imaging, with abdominal CT scan with contrast the preferred study.
Management
n
n
n
onsultation with surgery, hematology/oncology, and radiation therapy.
C
Endoscopic retrograde cholangiopancreatography (ERCP) for palliative treatment if surgery
not planned.
Counseling regarding diagnosis and advance directive.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Abdominal CT scan with contrast
•Pancreatic needle biopsy
THERAPY
•Advise patient, cancer diagnosis
•Advise patient, advance directive
•ERCP (if indicated)
•CBC
•BMP
•LFT
•Lipase
•CA 19-9, serum
•Chest CT scan with contrast
•Reassure patient
•Consult, hematology/oncology
•Consult, general surgery
•Consult, radiation therapy
MONITORING
LOCATION
TIMING
•None
•Office
•Diagnosis and management should be instituted within 4 days of simulated
time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Skin, HEENT, Abdominal, Lymph nodes ± Others
Abdominal CT scan with contrast, CBC, BMP, LFT,
Lipase, CA 19-9 serum
Advance clock to reschedule patient after results are
reported.
Pancreatic needle biopsy
Reschedule patient after biopsy results are reported.
Consult hematology/oncology, Consult general surgery,
Advise patient cancer diagnosis, Advise patient
advance directive, Reassure patient
Advance to additional results and case end.
None
73
6—FATIGUE
Case #28
Location: Office
Chief Complaint: Fatigue and loss of appetite
Case introduction
Initial vital signs
Initial history
•A 19-year-old white woman is brought to the office by her mother for
fatigue, loss of appetite, and weight loss over the past 5 months.
•Pulse: 55 beats/min
•Height: 162.5 cm (64.0 in)
•Weight: 42.1 kg (92.8 lb)
•Body mass index: 15.8 kg/m2
•The patient has had loss of appetite and increasing fatigue over the past
5 months. She feels she is overweight and constantly exercises, runs, and
eats only one meal a day. She has had difficulties focusing and concentrating on her studies and has had occasional episodes of dizziness. She
has a 4-month history of amenorrhea. She has never been sexually active.
There is no history of fever, constipation, or diarrhea
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, female; in no apparent distress.
Skin
Skin dry with reduced turgor. No nodules or other lesions. Nails brittle.
Breasts
Thin breasts, nipples normal; no masses.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae,
external auditory canals, and tympanic membranes, normal. Nose
and mouth normal. Pharynx normal. Neck supple; no masses or
bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous distention.
Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no
occult blood.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon
reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
74
II—CCS CASES BY CHIEF COMPLAINT
Case #28: Anorexia Nervosa
Keys to Diagnosis
n
n
n
ook for a thin, young woman with fatigue, bradycardia, and/or amenorrhea. Additional
L
symptoms include cold intolerance, dizziness, and low self-esteem.
Vital signs show low BMI and bradycardia. Examination may show a thin appearance, dry
skin, brittle nails, or lanugo.
Diagnosis of anorexia nervosa is based on history. Diagnostic workup should focus on complications, such as ECG abnormalities, hypokalemia, cytopenia, osteopenia, and other electrolyte abnormalities.
Management
n
n
n
dmit to hospital if ECG abnormalities, severe dehydration, electrolyte abnormalities, hyA
potension, suicidal thoughts, or rapid weight loss.
Consultation with psychiatry and dietary consult. Vitamin supplementation.
Correct electrolyte abnormalities.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•CBC
•BMP
•ECG, 12-lead
•Magnesium
•Phosphate
THERAPY
•DEXA scan (if amenorrhea >3 months)
•LFT
•TSH
•Prolactin
•FSH
•Depression index
•Urinalysis
•hCG, urine, qualitative
•Calcium gluconate (if hypocalcemia)
•Potassium phosphate (if hypophosphatemia)
•SSRI if depression present
•Potassium chloride (if
hypokalemia)
•Consult, psychiatry
•Consult, dietary
•ECG and electrolyte abnormalities should be monitored if present.
•New diagnosis with electrolyte or ECG abnormalities should be admitted to the
inpatient unit for workup and treatment.
•Diagnosis and management should be instituted within 1 day of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
General, Skin, Chest, Heart, Abdomen, Extremities ± Others
ECG 12-lead, BMP
Advance to ECG and BMP results.
Change to inpatient unit if patient presents in office and ECG
or electrolyte abnormality present.
Potassium chloride (if hypokalemia), CBC, Magnesium,
Phosphorus, LFT, TSH, (Prolactin, FSH, hCG if
amenorrhea), Depression index, Urinalysis
Advance clock to additional results.
Consult psychiatry, Consult dietary; SSRI if depression
present. Correct any additional electrolyte abnormalities.
Advance to additional results, patient updates and case end.
Daily ECG, BMP or other abnormal studies as needed.
75
6—FATIGUE
Case #29
Location: Office
Chief Complaint: Fatigue and dark urine
Case introduction
Initial vital signs
Initial history
•A 71-year-old white man presents to the office for a 2-month history of
fatigue and dark, tea-colored urine.
•Unremarkable.
•The patient has had increasing fatigue for the past 2 months, limiting
activities that he normally used to perform without problems. He also
notes intermittent episodes of dark, tea-colored urine. He occasionally
has had mild left flank pain. He has had a 15-lb weight loss over the
past 2 months without a change in appetite or dieting. There is no history of fever, constipation, or diarrhea.
•Past medical history is unremarkable.
•Social history includes smoking one-half pack a day of cigarettes for
the past 35 years.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Pale conjunctivae, funduscopic
examination normal. Hearing normal. Ears, including pinnae,
external auditory canals, and tympanic membranes, normal. Nose
and mouth normal. Pharynx normal. Neck supple; no masses or
bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous distention.
Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no
occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No
edema. Peripheral pulses normal. No joint deformity or warmth;
full range of motion. Spine examination shows left flank mass and
tenderness.
What is the suspected diagnosis, and what are the next steps in management?
76
II—CCS CASES BY CHIEF COMPLAINT
Case #29: Renal Cell Carcinoma
Keys to Diagnosis
n
n
n
he classic triad is flank pain, hematuria, and palpable abdominal/flank mass. Patients may
T
also present with fatigue from anemia, weight loss, dark or tea-colored urine, or hypertension.
On exam, look for abdominal or flank mass or tenderness.
Diagnosis is based on imaging, with renal ultrasound or CT with contrast preferred. Also
look for anemia, hepatic dysfunction, and electrolyte abnormalities. Evaluate for other causes
of fatigue as well.
Management
n
n
n
urgical consult or nephrectomy is the standard treatment for most tumors. For metastatic
S
tumors, consult oncology and radiation therapy.
Correct anemia if present.
Counseling regarding cancer diagnosis.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Abdomen, Rectal
•Exam: Skin, HEENT, Heart, Lungs, Lymph
•Urinalysis
nodes
•Urine cytology
•BMP
•Abdominal CT scan with
•TSH
contrast (or ultrasound)
•LFT
•CBC
•Fasting glucose
•Ferritin
•PT/PTT
•Iron and TIBC
•Chest CT scan
•Advise patient, no smoking
•Diet, high iron
•Advise patient, cancer
•Consult, hematology/oncology
diagnosis
•Consult, general surgery
•Nephrectomy
•Reassure patient
•Iron sulfate
•CBC
•Office
•Diagnosis and management should be instituted within 4 days of simulated
time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Abdomen, Rectal + Skin, HEENT, Heart, Lungs, Lymph nodes
Abdominal ultrasound, CBC, BMP, LFT, TSH, Glucose fasting,
Urinalysis, Urine cytology, Advise patient no smoking
Advance clock to reschedule patient when all results are
reported.
Abdominal CT scan, Chest CT scan, Ferritin, Iron studies,
PT/PTT, Advise patient cancer diagnosis, Reassure patient.
Advance clock to reschedule patient when all results are
reported.
Nephrectomy (or Consult general surgery), Consult hematology/
oncology, Iron sulfate, Diet high iron.
Advance to additional results and case end.
CBC in one month
77
6—FATIGUE
Case #30
Location: Office
Chief Complaint: Fatigue and epigastric pain
Case introduction
Initial vital signs
Initial history
•A 58-year-old Latino man presents to the office with a 2-year history
of fatigue and epigastric pain.
•Unremarkable.
•The patient has had a 2-year history of epigastric pain typically occurring 30 minutes after a meal. The pain is generally relieved with
antacids and is rated 4 on a 10-point scale. These episodes used to
occur every few weeks but now occur several times a week. He also
notes increasing fatigue over the past several months, with tiredness
performing routine activities. There is no history of constipation, diarrhea, dark stools, or fever.
•Past medical history of osteoarthritis treated with over-the-counter
aspirin.
•Family history, social history, and review of systems are
­unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth
normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no
occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No
edema. Peripheral pulses normal. No joint deformity or warmth; full
range of motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon
reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
78
II—CCS CASES BY CHIEF COMPLAINT
Case #30: Gastritis
Keys to Diagnosis
n
n
n
ommon symptoms include a chronic history of epigastric pain, abdominal tenderness,
C
bloating, anorexia, nausea, foul breath, and fatigue from anemia. Look for a history of
NSAID or alcohol use.
Exam is generally unremarkable.
Diagnosis is based on history and confirmed with endoscopy. Test for Helicobacter pylori,
anemia, and vitamin B12 deficiency.
Management
n
n
ifestyle modifications—diet, exercise, weight loss, smoking, alcohol, avoid NSAIDs.
L
Treat with PPI (e.g., omeprazole, oral). If H. pylori present, triple therapy with PPI +
amoxicillin and metronidazole (other regimens available: replace amoxicillin with clarithromycin if penicillin allergy). Confirm H. pylori eradication with stool antigen test after
4 weeks.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Endoscopy, upper gastrointestinal
•Urea breath test or H. pylori biopsy
•CBC
•Ferritin (if anemia present)
THERAPY
•BMP
•LFT
•Iron and TIBC
•Fasting glucose
•TSH
•Vitamin B12
•Advise patient, sit upright after
meals
•Omeprazole, oral, continuous (add
Amoxicillin and metronidazole if
H. pylori positive)
•Advise patient, no smoking
•Advise patient, limit alcohol intake
•Advise patient, avoid NSAIDs
•If H. pylori positive, stool antigen test in 4 weeks to evaluate for eradication.
•Manage as an outpatient.
•Diagnosis and management should be instituted within 4 days of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Order
Complete
CBC, Endoscopy upper GI, Urea breath test, BMP, LFT, Glucose
fasting, TSH, Advise patient no smoking, Advise patient limit
alcohol intake, Advise patient avoid NSAIDs
Advance clock to reschedule patient after results are reported.
Omeprazole (+ amoxicillin, metronidazole if H. pylori positive),
(Ferritin, Iron & TIBC, Vitamin B12 if anemia present), Advise
patient sit upright after meals
Advance clock to reschedule patient for follow-up appointment
in 4 weeks.
H. pylori stool antigen test in 4 weeks
79
6—FATIGUE
Case #31
Location: Office
Chief Complaint: Fatigue and epigastric pain
Case introduction
Initial vital signs
Initial history
•A 57-year-old white man presents to the office with a 3-month history of
fatigue and epigastric pain.
•Unremarkable.
•The patient has had a 3-month history of epigastric pain typically occurring after a meal. The pain is generally relieved with antacids and is
rated 6 on a 10-point scale. The painful episodes occur several times a
week. He also notes increasing fatigue over the past several months, with
tiredness performing routine activities. There is no history of constipation,
diarrhea, or fever.
•Past medical history of osteoarthritis treated with over the counter aspirin.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth
normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult
blood positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No
edema. Peripheral pulses normal. No joint deformity or warmth; full
range of motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon
reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
80
II—CCS CASES BY CHIEF COMPLAINT
Case #31: Peptic Ulcer Disease
Keys to Diagnosis
n
n
n
ommon symptoms include a chronic history of epigastric pain or tenderness, bloating, anC
orexia, nausea, foul breath, and fatigue from anemia. Look for a history of NSAID or alcohol
use.
Vital signs may show tachycardia or pallor. Rectal exam may show occult blood in stool.
Diagnosis is based on history and confirmed with endoscopy. Test for H. pylori, anemia and
vitamin B12 deficiency.
Management
n
n
reatment is similar to gastritis. Lifestyle modifications—diet, exercise, weight loss, smokT
ing, alcohol, and avoid NSAIDs.
Treat with PPI (e.g., omeprazole, oral). If H. pylori present, triple therapy with PPI + amoxicillin and metronidazole (other regimens available: replace amoxicillin with clarithromycin if
penicillin allergy). Confirm H. pylori eradication with stool antigen test after 4 weeks.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Endoscopy, upper gastrointestinal
•Urea breath test or H. pylori biopsy
•CBC
•Ferritin
THERAPY
•BMP
•LFT
•Iron and TIBC
•Fasting glucose
•TSH
•Vitamin B12
•Advise patient, sit upright after
meals
•Omeprazole, oral, continuous (add
•Amoxicillin and metronidazole if
H. pylori positive)
•Advise patient, no smoking
•Advise patient, limit alcohol intake
•Advise patient, avoid NSAIDs
•If H. pylori positive, stool antigen test in 4 weeks to evaluate for
eradication.
•Manage as an outpatient.
•Diagnosis and management should be instituted within 4 days of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Order
Complete
CBC, Endoscopy upper GI, Urea breath test, BMP, LFT,
Glucose fasting, TSH, Advise patient no smoking, Advise
patient limit alcohol intake, Advise patient avoid NSAIDs
Advance clock to reschedule patient after results are
reported.
Omeprazole (+ amoxicillin, metronidazole if H. pylori
positive), (Ferritin, Iron & TIBC, Vitamin B12 if anemia
present), Advise patient sit upright after meals
Advance clock to reschedule patient for follow-up
appointment in 4 weeks.
H. pylori stool antigen test (if H. pylori positive) in 4 weeks.
81
6—FATIGUE
Case #32
Location: Office
Chief Complaint: Fatigue and confusion
Case introduction
Initial vital signs
Initial history
•A 51-year-old Latina woman is brought to the office by her daughter for a
2-month history of fatigue and tiredness.
•Unremarkable.
•The patient has had increasing fatigue and tiredness over the past 2 months.
Her daughter notes that she has had confusion and episodes of memory
loss as well. Her mother often forgets appointments and gets tired easily on
their normal walks. She has had occasional bouts of tongue pain. The patient
drinks six to seven alcoholic drinks a day and has a diet of mainly fast-food
items. There is no history of chest pain, shortness of breath, fever, constipation, or diarrhea.
•Past medical history is unremarkable.
•Social history includes smoking two packs of cigarettes a day for the past
20 years.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Pale skin. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes show pale conjunctivae. Funduscopic
examination normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Tongue enlarged and
reddened. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen with mild hepatosplenomegaly. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
delayed.
What is the suspected diagnosis, and what are the next steps in management?
82
II—CCS CASES BY CHIEF COMPLAINT
Case #32: Vitamin B12/Folate Deficiency
Keys to Diagnosis
n
n
n
ook for a patient with heavy alcohol use or a malabsorption syndrome. Symptoms may
L
include fatigue, weakness, tongue pain, memory loss, or paresthesias.
On exam, may see paleness, tongue abnormalities or decreased deep tendon reflexes.
Diagnosis made by CBC, vitamin B12, folate levels. If B12 level is at lower end of normal,
check methylmalonic acid. Look for concurrent iron deficiency.
Management
n
n
itamin B12 and/or folate supplementation.
V
Counseling regarding alcohol use, diet.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: HEENT, Neuro
•CBC
•LFT
•Vitamin B12, serum
•Folic acid, serum
THERAPY
•Exam: Complete
•BMP
•TSH
•Glucose, fasting
•Ferritin
•Iron and TIBC
•PT/PTT
•Thiamine, therapy (Vitamin B1)
•Consult, dietary
•Reassure
•Counsel patient
•Advise patient, no smoking
•Advise patient, no alcohol
•Alcoholics Anonymous
•Vitamin B12 therapy
•Folic acid therapy
•CBC
•Office
•Diagnosis and management should be instituted within 4 days of
simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
CBC, BMP, LFT, TSH, Glucose fasting, Advise patient
no smoking, Advise patient no alcohol, Alcoholics
Anonymous
Advance clock to reschedule patient when all results
are reported.
Vitamin B12, Folic acid, Ferritin, Iron and TIBC, PT/PTT
Advance clock to reschedule patient when all results
are reported.
Vitamin B12 therapy, Folic acid therapy, Thiamine,
Consult dietary, Counsel patient
Advance to additional updates and case end.
CBC in 3 months
83
6—FATIGUE
Case #33
Location: Office
Chief Complaint: Fatigue and weight loss
Case introduction
Initial vital signs
Initial history
•A 57-year-old man presents to the office with a 3-month history of fatigue.
•Unremarkable.
•The patient has had a 3-month history of increasing fatigue and tiredness.
He gets easily tired doing activities, such as gardening, that did not used to
cause problems. He has also had a 20-lb weight loss in the past 3 months
despite no change in appetite. He notes that he feels full with small meals.
There is no history of chest pain, shortness of breath, fever, constipation, or
diarrhea.
•Past medical history includes hypertension treated with hydrochlorothiazide.
•Social history includes smoking one-half pack a day for the past 30 years.
He drinks two to three alcoholic drinks every day.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes show pale conjunctivae. Funduscopic
examination normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth
normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult
blood positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
84
II—CCS CASES BY CHIEF COMPLAINT
Case #33: Gastric Cancer
Keys to Diagnosis
n
n
n
ommon symptoms include early satiety with meals, weight loss, fatigue, nausea/vomiting,
C
dysphagia, dyspepsia unrelieved by antacids, and epigastric pain.
Exam may show signs of anemia, rectal exam with occult blood positive, or rarely an epigastric mass.
Diagnosis is made by endoscopy, upper GI. Evaluate for anemia and stage for ­metastases.
Management
n
n
n
urgery with gastrectomy is the primary treatment. Consult hematology/oncology for highS
stage tumors.
Correct anemia related to iron or B12 deficiency.
Counseling.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•CBC
•Endoscopy, upper gastrointestinal
THERAPY
•BMP
•LFT
•Glucose, fasting
•TSH
•Urinalysis
•Depression index
•Abdominal CT scan with contrast
•Advise patient, advanced directive
•Consult, hematology/oncology
•Consult, general surgery (or
Gastrectomy)
•Advise patient, cancer diagnosis
•Advise patient, no smoking
•Advise patient, no alcohol
•None
•Unless the patient has severe anemia, this case can generally be managed as
an outpatient.
•Diagnosis and management should be instituted within 4 days of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Abdomen, Rectal ± Others
CBC, BMP, LFT, Glucose, fasting, TSH, Urinalysis,
Endoscopy upper GI
Advance clock to reschedule patient after biopsy results.
Consult surgery (or Gastrectomy), Ferritin, Iron and
TIBC, Vitamin B12, Advise patient cancer diagnosis,
Advise patient advanced directive, Advise patient
no smoking, Advise patient no alcohol, Chest CT,
Abdominal CT
Advance to next available results and case end.
Iron sulfate, vitamin B12 or folate therapy if deficient.
85
6—FATIGUE
Case #34
Location: Office
Chief Complaint: Fatigue and bone pain
Case introduction
Initial vital signs
Initial history
•A 4-year-old girl is brought to the office by her mother for a 3-day history of
fatigue and pain in her foot, arms, and back.
•Temperature: 38.6 degrees C (101.5 degrees F)
•Pulse: 148 beats/min
•Respiratory rate: 28/min
•The mother reports that the patient appears to get tired easily with normal
play. She gets short of breath and exhausted playing with her siblings after
a few minutes. She has complained of nonspecific pain in her foot, arms,
and back over the past few days. Her appetite and bowel movements are
normal. There is no history of constipation or diarrhea.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Child sitting on mother’s lap in no apparent distress.
Skin
Normal turgor. Petechiae present on legs. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes with pale conjunctivae.
Funduscopic examination normal. Hearing normal. Ears,
including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous
distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver
and spleen not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing.
Petechiae present on legs. No edema. Peripheral pulses
normal. No joint deformity or warmth; full range of motion. Spine
examination normal.
What is the suspected diagnosis, and what are the next steps in management?
86
II—CCS CASES BY CHIEF COMPLAINT
Case #34: Acute Lymphoblastic Leukemia
Keys to Diagnosis
n
n
n
n
Common symptoms relate to anemia (fatigue, pallor, tiredness), thrombocytopenia (bruising, purpura, petechiae), and leukopenia (infections). Other symptoms include bone pain,
oliguria, and mental status changes.
Vital signs may show fever or be normal.
Exam often nonspecific and may show pallor, bruising, petechiae or hepatosplenomegaly.
Diagnosis should be suspected on CBC with the presence of blasts. Bone marrow biopsy will
confirm the diagnosis. Additional tests to order include BMP, uric acid, LDH, and cultures.
Management
n
n
n
Chemotherapy is the mainstay of treatment. Admit patient and consult hematology/­
oncology.
Treat anemia and thrombocytopenia with transfusions if needed. Look for the presence of
leukemia in the CSF to determine need for intrathecal chemotherapy.
Empiric antibiotics (e.g., ceftazidime) often given.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Skin +
Others
•CBC
•Bone marrow biopsy, needle
•Bone marrow aspiration
•Lumbar puncture
•CSF cytology
THERAPY
•BMP
•Urinalysis
•PT/PTT
•LFT
•Urine culture
•Blood culture
•Uric acid
•LDH
•Ceftazidime, IV
•Reverse isolation
•Intravenous access
•Consult, hematology/
oncology
•Type and crossmatch, blood
•Transfusion, packed red
blood cells (if severe anemia)
•Monitoring of CBC, lab values, and bone marrow findings needed after therapy
initiated.
•If the patient presents in the office, admit to in patient unit.
•Diagnosis and management should be instituted within 1 day of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
Near complete exam
CBC
Advance clock to results.
Transfer to inpatient unit if case starts in office.
Bone marrow biopsy, Bone marrow aspiration,
BMP, Uric acid, LDH, LFT, Urinalysis, Type and
crossmatch blood, Urine culture, Blood culture, IV
access
Advance clock to bone marrow results.
Consult hematology/oncology, Lumbar puncture,
CSF cytology, Transfusion packed red blood cells
(if severe anemia), Counsel family, Reassure family/
patient
Advance to additional results, updates and case end.
None
6—FATIGUE
87
Fatigue—Key Points
n
n
n
n
wide variety of diseases can present with fatigue. Common causes to consider include
A
cancer, endocrine disorders (diabetes, hypothyroidism), anemia, and blood loss (peptic ulcer
disease, colon cancer).
A general panel of tests to keep in mind for patients who present with fatigue includes:
n Fasting glucose
n TSH
n CBC
n BMP
n LFT
n Depression index
n Urinalysis
Most of the screening studies are resulted in 1 to 2 days, so initial management often
involves rescheduling a stable patient for a return visit. However, for children with fatigue,
it is generally best to get a stat CBC on the first office visit (1 hour), then plan for additional
follow-up depending on the results.
Some patients will have more than one diagnosis, so even if one diagnosis is evident on the
initial presentation, it is generally useful to screen for other causes of fatigue (e.g., a patient
who appears to have lead poisoning may also have iron deficiency anemia).
C H A P T E R
7
Chest Pain
Key Orders*
Time to Results—ED
Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor,
continuous
Cardiac monitor
Chest X-ray, portable
ECG, 12-lead
ABG
Chest X-ray, PA/lateral
Cardiac echo
CBC with differential
BMP
PT/PTT
D-dimer, plasma
Troponin I, serum
Cardiac enzymes, serum
Cardiac angiography
Cardiac MRI, with gadolinium
Cardiac scan, gated blood
pool
Cardiac sestamibi scan,
exercise
Cardiac thallium scan,
dipyridamole
Cardiac thallium scan, exercise
Cardiac thallium scan, resting
Cardiac ultrasound, dobutamine
Cardiac ultrasound, stress
ECG stress test
Pulse oximetry
Monitor, continuous blood pressure
cuff
Monitor, cardiac
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
X-ray, chest, PA/lateral
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
D-dimer, plasma
Troponin I, serum
Cardiac enzymes, serum
Angiocardiography, right and left heart
MRI, cardiac, with gadolinium
Scan, gated cardiac blood pool
1 min
5 min
Scan, myocardium, sestamibi exercise
12 hr
Scan, myocardium, thallium
dipyridamole
Scan, myocardium, thallium exercise
Scan, myocardium, thallium resting
Echocardiography, dobutamine
Echocardiography, stress
Electrocardiography, exercise/stress
test
Antibody, antinuclear, serum
Antibody, anti-double-stranded DNA,
serum
Antibody, Smith, serum
12 hr
ANA, serum
Anti-ds DNA, serum
AntiSmith antibody, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
5 min
10 min
15 min
18 min
20 min
30 min
30 min
30 min
30 min
30 min
45 min
1 hr
1 hr
1 hr 30 min
2 hr
12 hr
12 hr
24 hr
24 hr
24 hr
24 hr
2 days
3 days
89
7—CHEST PAIN
Case #35
Location: Emergency Department
Chief Complaint: Chest pain worsened by inspiration
Case introduction
Initial vital signs
Initial history
•A 48-year-old Latino man comes to the emergency department because of leftsided chest pain that began 12 hours ago.
•Temperature: 38.6 degrees C (101.5 degrees F)
•Other vital signs unremarkable.
•The patient describes chest pain that began as a dull ache and has gradually worsened over the last 12 hours. The pain is now sharp, left-sided and is
rated 6 on a 10 point scale. The pain radiates to his neck and is worsened by
deep inspiration and lying down. Leaning forward helps to improve the pain. He
has not taken any medications for the pain and has never felt this type of pain
before. He does not have shortness of breath, nausea or vomiting.
•The patient had an upper respiratory tract infection 1 week ago.
•Family history, social history, and review of systems are otherwise unremarkable
INITIAL MANAGEMENT
Orders
•Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
99% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; leaning forward, in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. Pericardial friction rub present. Central and peripheral pulses
Cardiovascular
normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
90
II—CCS CASES BY CHIEF COMPLAINT
Case #35: Acute Pericarditis
Keys to Diagnosis
n
n
n
n
Chest pain typically is worse with inspiration and is relieved by sitting up or leaning forward.
It may simulate cardiac ischemia in location and radiation to arms, neck or back. Look for
recent history of infection.
On heart examination, pericardial friction rub present.
Diagnosis typically based on history and exam. ECG helps confirm diagnosis, which may
show diffuse ST-segment elevation or PR-segment depression.
Echocardiography rules out significant pericardial effusion. Troponin may be elevated if
myopericarditis is present.
Management
n
n
n
NSAID therapy (ibuprofen, naproxen) or colchicine. Corticosteroids are controversial, so
better to not order.
Rest, counsel, reassurance.
Admit patient if Temp > 38°C, effusion > 2 cm, severe pain, or hemodynamic compromise.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Heart
•ECG, 12-lead
•Echocardiography
THERAPY
•Exam: Additional
•Troponin I, serum x3
•CBC
•BMP
•Chest X-ray, portable
•Reassure patient
•NSAID (naproxen or ibuprofen or other)
•Advise patient, rest at home
•Monitor temperature (vital signs) daily.
•Most patients can be treated in the emergency department and sent home.
•Admit patient if Temp > 38°C, effusion > 2 cm, severe pain, or hemodynamic
compromise.
•Initial management should be performed within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Clock
End Orders
Heart, Lungs, Abdominal ± Others
ECG, 12-lead
Advance to ECG result.
Echocardiography, Troponin, CBC, BMP, CXR
Advance to echo results.
Naproxen (or other NSAID), Reassure patient, Advise patient rest
at home
Advance clock to additional patient updates
Change to inpatient unit or home depending on if high risk criteria
present.
Advance to additional updates and case end.
None
91
7—CHEST PAIN
Case #36
Location: Emergency Department
Chief Complaint: Chest pain and anxiety
Case introduction
Initial vital signs
Initial history
•A 36-year-old white woman is brought to the emergency department for chest
pain that began 3 hours ago.
•Unremarkable.
•The patient had chest pain that began abruptly 3 hours ago and was associated with tremor and anxiety. She describes palpitations and nausea during the
episode. The chest pain was rated 5 on a 10-point scale at its onset and has
now gone down to a 2. She experienced mild shortness of breath and dizziness
at the onset, which has now resolved.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; appears anxious.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
92
II—CCS CASES BY CHIEF COMPLAINT
Case #36: Panic Attack
Keys to Diagnosis
n
n
n
Look for young patient (20s–30s) with chest pain and no cardiac history. Symptoms acute in
onset and associated with fear, anxiety, and terror. Associated symptoms include palpitations,
sweating, shortness of breath, nausea, vomiting, lightheadedness, and dizziness.
Vitals and exam generally unremarkable.
Rule out MI (ECG, troponin × 3) and other causes of chest pain
Management
n
n
n
Benzodiazepines (e.g., alprazolam) are useful in the acute setting. Eventually switch to SSRI
(e.g., paroxetine) and discontinue benzodiazepine over 2 to 3 weeks.
Cognitive behavioral therapy is typically used but is not orderable on the CCS; therefore,
consider Consult with a psychologist or psychiatrist.
Reassure.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Heart, Lungs
•ECG, 12-lead
•Troponin × 3
THERAPY
•Exam: Additional
•CBC
•BMP
•Chest X-ray, portable
•D-dimer
•Consult, psychologist (or psychiatrist)
•Alprazolam, oral
•Reassure patient
•Monitor symptoms as an outpatient.
•Manage as an outpatient.
•Initial management should be performed within 4 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Clock
End Orders
General, HEENT, Heart, Lungs, Abdomen, Extremities ± Others
ECG, CXR, CBC, BMP, Troponin × 3, D-dimer
Advance to results.
Alprazolam, Reassure patient
Advance clock for patient update.
Consult psychologist (or psychiatrist)
Advance to additional results of consult and troponins.
Change to home
Advance to additional updates and case end.
Order SSRI and delete benzodiazepine in 2 to 3 weeks if time allows.
93
7—CHEST PAIN
Case #37
Location: Office
Chief Complaint: Chest pain and dyspnea
Case introduction
Initial vital signs
Initial history
•A 39-year-old Chinese-American woman arrives at the office for a 2-week
history of chest pain.
•Temperature: 38.0 degrees C (100.4 degrees F)
•The chest pain began as a mild ache two weeks ago and is now a sharp pain
on both sides of the chest rated a 5 on a 10-point scale. The chest pain is
nonradiating, worsens with deep inspiration, and is associated with shortness
of breath and a nonproductive cough. She also describes pain in the joints of
her feet and hands over the last 2-3 months. She says she gets a rash on her
face and arms when she spends time out in the sun. There is no history of
chills, constipation, or diarrhea.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; mild shortness of breath.
Skin
Normal turgor. Malar rash present on face. No nodules or other lesions. Hair and
nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Mouth with mucosal ulcers present. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Dullness and decreased breath sounds at the lung bases.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and peripheral
Cardiovascular
pulses normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. No adnexal
masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Mild swelling in the joints of the hands and feet with normal range of motion. No
edema. Peripheral pulses normal. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
94
II—CCS CASES BY CHIEF COMPLAINT
Case #37: Systemic Lupus Erythematosus
Keys to Diagnosis
n
n
n
n
Look for a young woman who presents with chest pain, joint pain, rash, and/or photosensitivity.
On exam, look for rash, joint swelling, signs of pleural effusion, signs of pericarditis, and oral
ulcers.
Order ANA along with anti-ds DNA and anti-Smith antibody for confirmation of lupus.
Evaluate CBC (for cytopenia), urinalysis (for proteinuria), BMP (renal function), PTT and
anti-cardiolipin antibodies (for lupus anticoagulant), chest X-ray (if signs of pleural effusion), and echocardiogram (for valvular disease).
Management
n
n
n
n
Mild pleural effusion can be treated with analgesics. More severe effusions require thoracentesis.
Rheumatology consult is standard (although it may not yield much on the CCS).
Advise sunscreen and avoid sunlight if photosensitivity. NSAIDs for joint pain. Hydroxychloroquine useful in relieving skin inflammation, oral sores, fatigue and joint pain as well
as preventing relapse. Topical corticosteroids for discoid lesions. Cyclophosphamide if lupus
nephritis present.
Corticosteroids if CNS involvement, hemolytic anemia, or thrombocytopenia present.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Chest X-ray, PA/lateral
•ANA serum
•Anti-ds DNA, serum
•Anti Smith antibody, serum
THERAPY
•Ibuprofen, oral
•Hydroxychloroquine sulfate,
oral
•Prednisone, oral (if indicated)
•Sun screen topical
•Advise patient, avoid sun
•None
•CBC
•BMP
•PT/PTT
•Anti-cardiolipin antibody
•Urinalysis
•Echocardiogram
•HCG, beta, urine, qualitative (if young female)
•Consult rheumatology
•Advise patient, side effects of medication
•Reassure patient
MONITORING
LOCATION
TIMING
•Admit to inpatient unit if presence of pericarditis, myocarditis, pleural effusion,
vasculitis, cerebritis, or renal insufficiency.
•Diagnosis and management should be instituted within 2 days of simulated time.
SEQUENCING Exam
Orders
Clock
Location
Orders
Complete
Chest X-ray PA/lateral, Pulse oximetry
Advance to results of chest x-rays.
Change to inpatient unit.
CBC, BMP, PT/PTT, Urinalysis, ANA serum, anti-ds DNA, antiSmith
antibody
Clock
Advance clock to results of ANA.
Orders
Ibuprofen, Hydroxychloroquine, Consult rheumatology, Sun screen
topical, Advise patient avoid sun, Advise patient side effects of
medication, Advise patient medication compliance, Reassure patient
Clock
Advance to additional results and updates.
Exam
Lung, skin, extremities (Check for improvements)
Clock
Advance to additional updates and case end.
End Orders None
95
7—CHEST PAIN
Case #38
Location: Office
Chief Complaint: Chest pain related to exertion
Case introduction
Initial vital signs
Initial history
•A 54-year-old African American man presents to the office with a 2-month
history of chest pain.
•Height: 161.3 cm (63.5 in)
•Weight: 77.4 kg (170.6 lb)
•Body mass index: 29.7 kg/m2
•The patient has a 2-month history of intermittent chest pain that is left sided,
sharp, and severe, lasting for several minutes and then relieved with rest. The
pain is associated with nausea and diaphoresis and predominantly occurs
when the patient is exercising or running. He has mild shortness of breath
during the episodes. He has not experienced chills, vomiting, dark stools or
diarrhea.
•Past medical history of hypercholesterolemia.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, overweight male; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
96
II—CCS CASES BY CHIEF COMPLAINT
Case #38: Stable Angina
Keys to Diagnosis
n
n
n
Look for a patient with chest pain that is typically chronic, left sided, sharp, severe and related to exertion or exercise while relieved with rest. Patients may present with shortness of
breath, nausea, sweating, anxiety, or other symptoms as well. Vital signs may show patient is
overweight.
Examination is generally unremarkable.
Resting ECG may be normal. The diagnosis is based on the history but is confirmed with
an exercise ECG or dobutamine echocardiography showing ischemia. Background labs to
measure include CBC, BMP, lipid panel, and LFT.
Management
n
n
n
Lifestyle modifications: diet, exercise, weight loss, smoking, alcohol.
If exercise ECG or stress echocardiography positive, order coronary angiography to evaluate
extent of occlusion and consult cardiology for need for revascularization.
Medications include: aspirin, beta blocker (Ex. metoprolol), Statin (Ex. Atorvastatin), ACE
inhibitor (Ex. ramipril).
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•ECG, 12-lead
•CBC
•ECG, exercise
•BMP
•Lipid profile
•Glucose, fasting
•Coronary angiography
•LFT
•Aspirin
•Advise patient, medication
•Atorvastatin, oral
compliance
•Metoprolol, oral
•Advise patient, side effects of
•Ramipril, oral
medication
•Consult cardiology
•Counsel patient
•Advise patient, no smoking
•Reassure patient
•Diet, low fat
•Advise patient, limit alcohol
•Diet, calorie restricted
•Advise patient, exercise program
•Not important for this case
•Stable angina patients can be managed as outpatients. If unstable angina,
admit to the emergency department.
•Initial management should be performed within 3 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Heart, Abdomen, Rectal ± Additional
ECG 12-lead
Advance clock to results of ECG.
ECG stress test, CBC, BMP, LFT, Glucose fasting serum, Lipid
profile, Advise patient no smoking, Advise patient limit alcohol,
Diet low fat, Diet calorie restricted.
Reschedule patient after all results are reported.
Coronary angiography
Reschedule patient after results of angiography.
Consult cardiology, Aspirin, Atorvastatin, Metoprolol, Ramipril,
Advise patient exercise program, Advise patient medication
compliance, Advise patient side effects of medication, Counsel
patient, Reassure patient
Advance clock to additional results, updates and case end.
None
7—CHEST PAIN
97
Chest Pain—Key Points
n
n
n
or most cases, the diagnosis should be evident from the history. However, even if you are
F
sure of the diagnosis, you still need to rule out other differentials and confirm the diagnosis.
For example, you may know the patient has aortic dissection, but you still need to rule out
myocardial infarction, pulmonary embolism, and so forth
Important diagnostic studies to consider in patients who present with chest pain include:
n ECG, 12-lead
n Chest X-ray, PA/lateral
n Troponin (“cardiac enzymes” can also be ordered, but take longer and CPK fractions do
not really add much more to the troponin results in most cases).
n D-dimer
n CBC
n BMP
For cases needing urgent surgical intervention, such as aortic dissection, make sure to stabilize the blood pressure and pain before ordering surgical consult or surgery.
C H A P T E R
8
Altered Mental Status
Key Orders*
Order
CCS Terminology
Time to Results—
ED Setting (Stat)
Pulse oximetry
Fingerstick glucose
Blood pressure monitor, continuous
Cardiac monitor
Pregnancy test, urine
Chest X-ray, portable
ECG, 12-lead
Ketone bodies, serum, qualitative
ABG
Urinalysis
Vaginal Gram stain
Ketone bodies, serum, quantitative
Alcohol, blood
Head CT without contrast
Echocardiography
CBC with differential
BMP
PT/PTT
D-dimer, plasma
Acetaminophen, serum
Acetaminophen toxicity nomogram
Troponin
Ammonia, blood
Beta-hydroxybutyrate, blood
Retic count
LFT
Osmolality, serum
Fibrin breakdown products
Toxicology screen, serum
Toxicology screen, urine
Cerebral angiography
Phosphate, serum
Magnesium, serum
Coombs’, direct, complement
Haptoglobin, serum
B12, serum
Vaginal culture
Urine culture
Blood culture
Pulse oximetry
Glucose, blood, random, by Glucometer
Monitor, continuous blood pressure cuff
Monitor, cardiac
hCG, beta, urine, qualitative
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Ketone bodies, serum, qualitative
Arterial blood gases
Urinalysis
Gram stain, vaginal secretions
Ketone bodies, serum, quantitative
Ethanol, serum
CT, head, without contrast
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
D-dimer, plasma
Acetaminophen, serum
Acetaminophen toxicity nomogram
Troponin I, serum
Ammonia, blood
Beta-hydroxybutyrate, blood
Reticulocyte count, blood
Liver function panel
Osmolality, serum
Fibrin breakdown products
Toxicology screen, serum
Toxicology screen, urine
Angiography, cerebral arteries
Phosphorus, serum
Magnesium, serum
Antiglobulin test, direct, complement, blood
Haptoglobin, serum
Vitamin B12, serum
Bacterial culture, vagina
Bacterial culture, urine
Bacterial culture, blood
1 min
2 min
5 min
5 min
5 min
10 min
15 min
15 min
18 min
20 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
45 min
1 hr
1 hr
1 hr
2 hr
2 hr
2 hr
2 hr
2 hr
3 hr
3 hr
4 hr
6 hr
10 hr
24 hr
24 hr
24 hr
30 hr
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
8—ALTERED MENTAL STATUS
99
Case #39
Location: Emergency Department
Chief Complaint: Loss of consciousness
Case introduction
Initial vital signs
Initial history
•A 34-year-old white woman is brought to the emergency department after
being found unconscious at her home by her neighbor.
•Pulse: 122 beats/min
•Respiratory rate: 8/min
•Blood pressure, systolic: 104 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient was found at home by a neighbor semiconscious in her bedroom.
The patient became progressively unresponsive in the ambulance just before
arrival. There were empty pill bottles found next to the patient, but the neighbor is unclear as to what was in the bottles. The patient is known to have a
history of depression.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, HEENT, Chest, Heart, Abdomen
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
87% on room air
Physical Exam Results (Pertinent Findings)
General
Patient lying motionless.
HEENT/Neck
Normocephalic. Eyes show mildly dilated pupils. Mouth with dry mucous
membranes. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Breathing rate reduced. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
Tachycardic. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses weak. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds reduced; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
100
II—CCS CASES BY CHIEF COMPLAINT
Case #39: Tricyclic Antidepressant Overdose
Keys to Diagnosis
n
n
n
The typical presentation is altered mental status or coma. You may see a history of depression
or prior suicidal attempts. Vital signs show hypotension, bradypnea, and tachycardia.
On exam, look for dilated pupils (mydriasis) and absent bowel sounds.
ECG typically shows QRS prolongation, tachycardia, and sometimes AV block. The diagnosis should be made before serum or urine toxicology results. Assess baseline labs: CBC, BMP,
and ABG. Rule out other causes in the differential and other coingested substances.
Management
n
n
n
Treatment is mainly supportive. ABCs—intubate if needed, oxygen. IV fluids for hypotension.
IV sodium bicarbonate if QRS prolonged or evidence of cardiotoxicity.
Nasogastric tube may show pill fragments. Decontamination with “activated charcoal” within 2 hours of ingestion may be considered. “Gastric lavage” within 1 hour of ingestion may
be considered for serious toxicity.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Lungs, Heart, HEENT, Abdomen
•ECG, 12-lead
•ABG
THERAPY
•Oxygen
•Intubation, endotracheal (if needed)
•Normal saline, 0.9% NaCl
•Sodium bicarbonate, IV
•Consult, poison control center
•Nasogastric tube
MONITORING
•Exam: Additional
•BMP
•Chest X-ray, portable
•CBC
•Alcohol, blood
•Head CT scan
•hCG, beta, urine, qualitative
•Toxicology screen, urine
•Suction airway
•Intravenous access
•Mechanical ventilation
•Activated charcoal
•Consult, psychiatry
•Gastric lavage
•Foley catheter
•Urine output
•ECG
•ABG
•Blood pressure monitor, continuous
•Cardiac monitor
•Pulse oximetry
•From emergency department, transfer to ICU after patient stabilized.
•Diagnosis and management should be instituted within 1 hour of simulated time.
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, Heart, Lungs, HEENT, Abdomen
Oxygen, Intravenous access, Normal saline, 0.9% NaCl, ECG 12lead, ABG. If indicated: Suction airway, Intubation endotracheal,
Mechanical ventilation.
Exam
Advance to results of ECG.
Orders
Sodium bicarbonate, Nasogastric tube, Activated charcoal, Consult
poison control center, Chest X-ray portable, CBC, BMP, Alcohol
blood, Acetaminophen serum, Foley catheter, Toxicology screen
urine, hCG urine, Urine output.
Clock
Advance to additional results and patient update.
Orders
ECG, ABG
Clock
Advance to results to verify improvement.
Location
Change to the ICU.
Clock
Advance to additional results, patient updates, and case end.
End Orders Consult, psychiatry
8—ALTERED MENTAL STATUS
101
Case #40
Location: Emergency Department
Chief Complaint: Loss of consciousness
Case introduction
Initial vital signs
Initial history
•A 51-year-old African American woman is brought to the emergency department by ambulance after being found unconscious at home by her daughter.
•Blood pressure, systolic: 178 mm Hg
•Blood pressure, diastolic: 92 mm Hg
•The patient was found unconscious in her living room by her daughter. She was
brought to the emergency department by ambulance and was intubated while
in transit. Her daughter reports she had been complaining of not feeling well
and having a headache earlier in the morning. She has also been feeling sad
and depressed over the past 2 months after finalizing a divorce. The daughter is
unsure of any other medical history.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Patient lying motionless; intubated.
HEENT/Neck
Normocephalic. Funduscopy shows papilledema and retinal hemorrhage.
Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Patient intubated.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with mechanical ventilation. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses with wide pulse pressure. No jugular venous distention.
Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
102
II—CCS CASES BY CHIEF COMPLAINT
Case #40: Subarachnoid Hemorrhage
Keys to Diagnosis
n
n
n
Although the classic presentation is “worst headache of my life,” a patient may also present
with altered mental status or coma on the CCS. Watch for distracters such as history of
depression or suicide attempts. Vital signs may show high blood pressure.
On exam, funduscopy may show papilledema or retinal hemorrhage. Variable neurologic
abnormalities may be present if patient conscious.
Diagnosis is made by head CT without contrast. Cerebral angiography should be ordered to
identify the source of bleeding.
Management
n
n
n
Initial management should include ABCs and strict blood pressure control (e.g., IV labetalol).
Pain control with morphine.
Neurosurgery consult if presence of aneurysm.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Head CT without contrast
•Cerebral angiography
THERAPY
•CBC
•BMP
•ECG, 12-lead
•PT/PTT
•Troponin
•ABG
•Chest X-ray, portable
•Oxygen
•Morphine, IV
•Foley catheter
•Urine output
•Intubation, endotracheal (if indicated)
•Labetalol, IV
•Consult, neurosurgery
•Blood pressure monitor
•Cardiac monitor
•Pulse oximetry
•The patient should be transferred to the ICU after diagnosis is established.
•Management should be instituted within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, HEENT, Heart, Lungs, Extremities, Neuro
Head CT without contrast, ECG 12-lead, Oxygen. If indicated:
Suction airway, Intubation endotracheal, Mechanical ventilation.
Advance to results of head CT.
Cerebral angiography, Labetalol, Morphine, CBC, BMP, PT/PTT,
Troponin, ABG, Chest X-ray, Foley catheter, Urine output
Advance to results of cerebral angiography.
Vital signs, Consult neurosurgery
Change to ICU.
Advance to additional updates and case end.
None
103
8—ALTERED MENTAL STATUS
Case #41
Location: Emergency Department
Chief Complaint: Altered mental status
Case introduction
Initial vital signs
Initial history
•A 31-year-old white woman is brought to the emergency department by ambulance after being found semiresponsive at home by her roommate.
•Respiratory rate: 10/min
•Blood pressure, systolic: 90 mm Hg
•Blood pressure, diastolic: 55 mm Hg
•The patient was found semiresponsive at home by her roommate after she came
home from work. The patient is known to have a history of anxiety and panic
attacks. She was transported to the emergency department by ambulance and
developed a progressive loss of consciousness during transport. She was given
oxygen in route.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, HEENT, Chest, Heart, Abdomen
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, female; drowsy, drifting out of consciousness.
HEENT/Neck
Normocephalic. Eyes show vertical nystagmus, funduscopic examination
normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Breathing rate reduced. Diaphragm and chest move
equally and symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses weak. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Neuro/Psych
Patient unresponsive. Deep tendon reflexes diminished.
What is the suspected diagnosis, and what are the next steps in management?
104
II—CCS CASES BY CHIEF COMPLAINT
Case #41: Benzodiazepine Overdose
Keys to Diagnosis
n
n
n
Look for a patient that is confused, disoriented, somnolent or has loss of consciousness.
Vitals may show hypotension and bradypnea.
On exam, HEENT shows vertical nystagmus, and neurologic exam shows that the patient is
not oriented with diminished muscle strength and reflexes.
Diagnosis is based on history and exam. ECG showing no QRS prolongation should make
tricyclic antidepressant overdose less likely. Urine or blood drug testing can confirm the
diagnosis, but for the CCS, treatment should be instituted before results of toxicology tests.
Management
n
n
n
Supportive care is the mainstay of therapy. ABCs—monitoring vital signs, oxygen, IV fluids,
intubation if severe respiratory depression.
Nasogastric tube may reveal pill fragments. Decontamination with “activated charcoal” within 4 hours is controversial but may be considered. “Gastric lavage” is generally not recommended. Flumazenil can reverse CNS depression but its use is controversial.
Consultation with poison control center, substance abuse unit or psychiatry may be considered.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, HEENT, Chest,
Heart, Neuro
•ECG, 12-lead
•ABG
THERAPY
•Oxygen
•Normal saline, 0.9% NaCl
•Intubation, endotracheal (if
needed)
•Consult, Poison control center
MONITORING
•Chest X-ray, portable
•Fingerstick glucose
•Head CT without contrast
•BMP
•LFT
•Urinalysis
•Toxicology screen, urine
•Alcohol, blood
•hCG, beta, urine, qualitative (if female)
•Intravenous access
•Nasogastric tube
•Flumazenil,IV
•Activated charcoal
•Consult, substance abuse unit
•Consult, psychiatry
•Cardiac monitor
•Pulse oximetry
•Blood pressure monitor
•Change to ICU after initial management in the ED.
•Initial management should be instituted within the first 1–2 hr before results of
urine or serum drug tests.
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, HEENT, Lung, Heart, Abdomen, Extremities, Neuro
ABG, ECG, Fingerstick glucose, Oxygen, Intravenous access,
Normal saline, Nasogastric tube, If needed: Intubation
endotracheal
Clock
Advance to results of ECG.
Orders
BMP, LFT, Urinalysis, Toxicology urine, Alcohol blood, Activated
charcoal, Flumazenil (optional)
Clock
Advance clock to additional results and patient update.
Exam
Interval/follow up, Lung, Neuro + Others
Orders
Consult poison control center, Vital signs
Location
Change to ICU.
Clock
Advance to additional results and case end.
End Orders Consult psychiatry, Consult substance abuse unit
8—ALTERED MENTAL STATUS
105
Case #42
Location: Office
Chief Complaint: Memory loss and forgetfulness
Case introduction
Initial vital signs
Initial history
•A 71-year-old white woman is brought to the office by her granddaughter for
an 8-month history of forgetfulness and memory loss.
•Unremarkable.
•The patient is described by her granddaughter as having increasing forgetfulness over the past 8 months, including forgetting phone numbers, addresses,
and people’s names. She has also been forgetting to balance her checkbook
and has had several bounced checks. A few days ago she forgot how to get
home on her normal evening walk. There is no history of fever, chest pain,
shortness of breath, constipation, or diarrhea.
•Past medical history includes four normal childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Elderly, thin, female; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Neuro/Psych
Mental status shows reduced recall. Findings on cranial nerve, motor, and
sensory examinations normal. Cerebellar function normal. Deep tendon
reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
106
II—CCS CASES BY CHIEF COMPLAINT
Case #42: Alzheimer’s Dementia
Keys to Diagnosis
n
n
n
Look for an older patient that presents with a several-month history of memory loss (forgetting names, phone numbers, addresses), poor grooming, difficulty recognizing objects,
language difficulty, and decreased comprehension.
On exam, mental state exam shows reduced recall and language.
Diagnosis is based primarily on history. Labs and imaging exclude other possible causes of
dementia.
Management
n
n
n
The mainstay of treatment is counseling and support.
Cholinesterase inhibitors (e.g., donepezil) for mild to moderate disease. NMDA antagonist
(e.g., memantine) for moderate to severe disease.
Treat any associated conditions, such as depression, agitation, and hallucinations.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: neurologic
•Exam: additional ± complete
•Head CT without contrast (or MRI)
•CBC
•Depression index
•BMP
•Vitamin B12, serum
•Folic acid, serum
•TSH
•ESR
•RPR, serum
•Toxicology screen, urine
•LFT
•Medications (e.g., donepezil or memantine, •Counsel patient
depending on severity)
•Reassure patient
•Advise patient, advance directive
•Monitor symptoms over several months.
•Generally, patients can be managed as outpatients.
•Management should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
Complete
CBC, BMP, TSH, LFT, Vitamin B12, ESR, Folic acid, RPR,
Toxicology screen urine, Head CT, Depression index
Advance clock to reschedule patient when all results are reported.
Donepezil, Advise patient advance directive, Counsel patient,
Reassure patient
Advance to additional patient updates and case end.
None
8—ALTERED MENTAL STATUS
107
Case #43
Location: Emergency Department
Chief Complaint: Lightheadedness, nausea, vomiting
Case introduction
Initial vital signs
Initial history
•A 22-year-old white woman is brought to the emergency department by
a friend for lightheadedness, nausea, and vomiting over the past 4 hours.
•Temperature: 38.4 degrees C (101.2 degrees F)
•Pulse: 120 beats/min
•Respiratory rate: 34/min
•Blood pressure, systolic: 108 mm Hg
•Blood pressure, diastolic: 67 mm Hg
•The patient describes chills, arthralgia, and myalgia beginning 3 days
ago. Over the past day, she describes increasing nausea and with one
episode of vomiting 2 hours ago. After vomiting, the patient went to lie
down and had one episode of lightheadedness upon arising. After resting again, she noted worsening lightheadedness, including near-syncope
on last attempt to stand. She also describes a rash beginning on her
arms and legs which is now generalized. She has not had any diarrhea,
shortness of breath, or chest pain. She is not sexually active, and there
is no recent travel history. She has normal menstrual cycles, with her last
period 1 week ago.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities,
Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; ill appearing.
Skin
Normal turgor. Diffuse maculopapular rash. Hair and nails normal.
Genitalia
Normal labia. Vagina swollen and erythematous. Uterus not enlarged. No adnexal
masses or tenderness.
Extremities/Spine
Maculopapular rash on arms and legs. Extremities symmetric without deformity,
cyanosis, or clubbing. No edema. Peripheral pulses normal. No joint deformity
or warmth; full range of motion. Spine examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
108
II—CCS CASES BY CHIEF COMPLAINT
Case #43: Toxic Shock Syndrome
Keys to Diagnosis
n
n
n
Look for a young woman with a recent onset of fever, mental status changes, and generalized
rash. Other symptoms include evidence of multiorgan involvement, such as nausea, vomiting, myalgia, diarrhea, pain, and headache. Vital signs show fever, tachycardia, and hypotension.
On exam, tampon may initially not be seen on genitalia exam. Skin exam shows rash.
Gram stain and culture of vagina or cervix should reveal evidence of Staphylococcus aureus or
Streptococcus pyogenes infection. Lab studies should be ordered to evaluate for multiorgan failure.
Management
n
n
n
n
ABCs with monitoring, oxygen, and treatment of hypotension with IV fluids or medications.
“Remove tampon” can be ordered directly in the CCS.
Antibiotic therapy: Multiple options exist. Ex. Clindamycin + Vancomycin
Surgical consult for possible wound debridement and infectious disease consult are generally
ordered.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Skin, Heart, Lungs, Genitalia
•Vaginal gram stain
•Vaginal culture
•Blood culture
THERAPY
•CBC
•Urinalysis
•PT/PTT
•BMP
•LFT
•ABG
•Consult, general surgery
•Consult, infectious disease
•Type and crossmatch, blood
•Norepinephrine or dopamine (if
needed for hypotension)
•Oxygen
•Intravenous access
•Normal saline, 0.9% NaCl
•Remove tampon
•Antibiotic (Ex. Clindamycin +
Vancomycin)
•Pulse oximetry
•Foley catheter
•Blood pressure monitor
•Urine output
•Cardiac monitor
•Admit to ICU or inpatient unit depending on severity.
•Management should be instituted within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Exam
Orders
Clock
Location
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia,
Extremities, Neuro
Vaginal Gram stain and culture, Oxygen, Normal saline, Intravenous
access
Advance to results of vaginal gram stain.
Genitalia (if tampon not previously visualized)
Remove tampon, Antibiotic (Ex. clindamycin + vancomycin),
Consult general surgery, Consult infectious disease, CBC, BMP,
PT/PTT, LFT, ABG, Blood culture, Foley catheter, Urine output
Advance to results of remove tampon.
Change to ICU
Advance to additional results, patient updates and case end.
None
8—ALTERED MENTAL STATUS
109
Case #44
Location: Office
Chief Complaint: Tremor
Case introduction
Initial vital signs
Initial history
•A 63-year-old Latino man arrives at the office with his son for a 5-month history of
tremor.
•Unremarkable
•The patient has been having increasing episodes of a fine tremor in his right
hand over the last 5 months. The tremor began in his thumb a few months ago
and now involves the entire right hand. The tremor has affected his ability to
play golf and to button his shirts when he gets dressed. The tremor typically
occurs when he is lying in bed or sitting on the sofa and goes away when the
patient is walking or gardening.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Resting tremor in right hand. Extremities symmetric without deformity,
cyanosis, or clubbing. No edema. Peripheral pulses normal. No joint
deformity or warmth; full range of motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve and sensory examinations
normal. Slowness of movement and rigidity with gait difficulties. Deep
tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
110
II—CCS CASES BY CHIEF COMPLAINT
Case #44: Parkinson’s Disease
Keys to Diagnosis
n
n
n
ook for an older patient with an asymmetric resting tremor, slowness of movement, rigidity,
L
and gait difficulty. Other symptoms include urinary retention and erectile dysfunction.
On exam, look for tremor and gait abnormalities on neuro exam.
Diagnosis is based on history and exam. If the diagnosis is unclear, order MRI to exclude
stroke, tumor, and hydrocephalus. Evaluate for depression. In patients younger than 40 years,
screen for Wilson’s disease with serum ceruloplasmin.
Management
n
n
n
ymptomatic: reassurance, counseling, physical therapy.
S
Dopamine replacement therapy: levodopa and carbidopa (e.g., Sinemet) for symptomatic
treatment.
Neurology consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: neurologic
•Depression index
•Exam: additional ± complete
•MRI, head
•Ceruloplasmin, serum
(if age <40 years)
•Levodopa/carbidopa
•Counsel patient
•Consult, physical therapy
•Reassure patient
•Consult, neurology
•Monitor symptoms after onset of therapy.
•Patients can generally be managed as outpatients.
•Initial management should be instituted within 4 days.
Exam
Orders
Clock
Orders
Clock
End Orders
General, Extremities, Neuro ± Complete
Depression index, (MRI head optional)
Advance clock to results of depression index.
Levodopa-/carbidopa, Counsel patient, Reassure patient, Consult
physical therapy, Consult neurology
Advance to additional patient updates and case end.
None
8—ALTERED MENTAL STATUS
111
Case #45
Location: Emergency Department
Chief Complaint: Confusion and lethargy
Case introduction
Initial vital signs
Initial history
•A 61-year-old white woman is brought to the emergency department for confusion and lethargy.
•Temperature: 38.4 degrees C (101.1 degrees F)
•Pulse: 118 beats/min
•The patient developed worsening confusion over the past 4 hours while at work.
She appeared drowsy to her coworkers and was becoming increasingly less
responsive. She has complained of nausea and vomiting over the past 3 days
and has not been eating or drinking fluids adequately. She has a history of diabetes mellitus but has not monitored her blood sugar levels in the past week.
•Past medical history of type II diabetes mellitus treated with metformin.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, obese, female; ill-appearing and drowsy.
Skin
Skin turgor reduced. No nodules or other lesions. Hair and nails normal.
HEENT/Neck
Normocephalic. Funduscopic examination shows blot hemorrhages and
microaneurysms. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal.
Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
Tachycardic. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
112
II—CCS CASES BY CHIEF COMPLAINT
Case #45: Hyperosmolar Hyperglycemic State
Keys to Diagnosis
n
n
n
Look for a patient with a known history of diabetes who presents with altered mental status
changes, reduced appetite, nausea, vomiting, and weakness. Compared with diabetic ketoacidosis, symptoms typically develop more slowly over days, and there is absence of abdominal
pain. Vital signs may show tachycardia and fever.
On exam, look for signs of dehydration with decreased skin turgor and diabetic changes on
funduscopy, such as hemorrhages and microaneurysms.
Diagnosis is based on hyperglycemia, hyperosmolarity, and absence of ketoacidosis. Fingerstick glucose showing hyperglycemia, ABG showing absence of acidosis, and urinalysis showing
absence of ketones should initially lead to the diagnosis. Patients may also present with other
secondary diagnoses such as infections, sepsis, myocardial infarction, pneumonia, or DVT/PE.
Management
n
n
Diagnosis and management are similar to those for diabetic ketoacidosis. Correct fluid loss
with intravenous fluids, correct hyperglycemia with insulin, correct electrolyte disturbances
(particularly potassium), and correct acid-base balance.
Treat associated infections or cardiac ischemia, if present.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Fingerstick glucose
•ABG
•Urinalysis
•Ketone bodies, serum, qualitative
•Osmolality, serum
•BMP
•hCG, beta, urine, qualitative (if female)
THERAPY
•Normal saline solution, 0.9% NaCl
•Insulin, regular, IV
MONITORING
•ECG, 12-lead
•Troponin I
•CBC
•Blood culture
•Urine culture
•Phosphorus
•Magnesium
•LFT
•Intravenous access
•Potassium chloride (if hypokalemia)
•Diabetes education (at a later time)
•BMP, hourly
•Blood pressure monitor
•Cardiac monitor
•Pulse oximetry
•Blood glucose, hourly
•After initial diagnosis and management, change location to ICU for monitoring.
•Management should be instituted within the first 2 hours of simulated time.
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
Orders
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities ± Others
Fingerstick glucose
Advance to results of fingerstick glucose.
Intravenous access, Normal saline, ABG, Urinalysis, Ketone
bodies qualitative, Osmolality, BMP, hCG urine (if female), ECG,
Troponin I, CBC, Blood culture, Urine culture, Phosphorus,
Magnesium
Advance to results of individual studies about 30 min.
Insulin regular IV, Potassium chloride (if hypokalemia)
Transfer to ICU.
Advance clock to 1 hour.
Fingerstick glucose, BMP hourly
Advance clock to additional results and patient updates.
Diabetes education.
8—ALTERED MENTAL STATUS
113
Case #46
Location: Emergency Department
Chief Complaint: Loss of consciousness
Case introduction
Initial vital signs
Initial history
•A 23-year-old white man is brought to the emergency department by ambulance after being found unconscious outside a nightclub.
•Pulse: 38 beats/min
•Respiratory rate: 8/min
•Blood pressure, systolic: 105 mm Hg
•Blood pressure, diastolic: 65 mm Hg
•The patient was found by bystanders outside a nightclub initially to be drowsy
and confused and progressively developed loss of consciousness. He had no
signs of trauma and witnesses did not report any fall or injuries. By the time
ambulance personnel arrived, he was unresponsive. He was intubated before
arrival in the emergency department.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Patient unconscious; intubated.
HEENT/Neck
Normocephalic. Pupils with miosis. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Endotracheal tube in place;
thyroid normal.
Heart/Cardiovascular
Bradycardia. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses weak. No jugular venous distention. Blood
pressure equal in both arms.
Chest/Lung
Chest wall normal. Respiratory rate reduced. No abnormality on percussion
or auscultation.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses weak. No joint deformity or warmth. Spine examination
normal.
What is the suspected diagnosis, and what are the next steps in management?
114
II—CCS CASES BY CHIEF COMPLAINT
Case #46: Opioid Toxicity
Keys to Diagnosis
n
n
n
Look for a patient who presents with loss of consciousness. Vital signs show hypotension,
bradypnea, and bradycardia.
On exam, HEENT exam shows miosis. Also look for a weak pulse and reduced respiratory
effort.
Diagnosis is based on history, vital signs, and exam. Do not wait for urine or blood toxicology
results to start therapy. If IV drug user, evaluate for hepatitis, HIV.
Management
n
n
n
Treatment with naloxone should be instituted after a brief exam with an initial cocktail of
glucose, thiamine, and naloxone.
ABCs—monitoring, oxygen, intubation if needed. IV fluids for hypotension.
Counseling and psychiatry consult.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Lungs, Heart, HEENT, abdomen
•ECG, 12-lead
•Fingerstick glucose
THERAPY
•Exam: Additional
•ABG
•BMP
•CBC
•LFT
•Troponin I
•Urinalysis
•hCG, beta, urine, qualitative
(if female patient)
•Toxicology screen, urine
•Intravenous access
•Mechanical ventilation (if needed)
•Nasogastric tube
•Consult, psychiatry
•Oxygen
•Intubation, endotracheal (if needed)
•Normal saline, 0.9% NaCl
•Naloxone, IV
•Consult, poison control center
•Consult, substance abuse center
•Blood pressure monitor
•Cardiac monitor
•Pulse oximetry
•Admit to ICU for initial monitoring.
•Treatment with naloxone should be instituted within 15 minutes.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Location
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, HEENT, Heart, Lungs
Oxygen, Intravenous access, Normal saline, 0.9% NaCl, Naloxone,
Thiamine, Fingerstick glucose, ECG 12-lead, ABG (If needed—
Suction airway, Intubation endotracheal, Mechanical ventilation)
Advance to results of ECG
CBC, BMP, LFT, PT/PTT, Troponin, Alcohol blood, Acetaminophen
serum, Foley catheter, Urinalysis, Toxicology screen urine, hCG
urine (if female), Consult poison control center
Advance to additional results
Change to ICU
Advance to additional results or patient updates.
Consult psychiatry, Consult substance abuse center, Counsel
patient, Reassure patient
8—ALTERED MENTAL STATUS
115
Case #47
Location: Emergency Department
Chief Complaint: Altered mental status and lethargy
Case introduction
Initial vital signs
Initial history
•A 46-year-old Latino man is brought to the emergency department by his wife
for a 2-day history of altered mental status.
•Unremarkable.
•The patient’s wife states he has been having difficulty concentrating and
increasing lethargy over the past 2 days. He has decreased short-term
memory and difficulty performing simple tasks at home. He has had trouble
recognizing the time of day and has had fits of anger over the past week. He
has a long history of alcohol use and is known to have cirrhosis but has not
had alcohol in 6 months. He does not have any recent travel history. There is
no history of chest pain, shortness of breath, diarrhea, or constipation.
•Past medical history of alcoholic hepatitis and cirrhosis diagnosed 2 years
ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Patient lying in bed; in no apparent distress.
Skin
Normal turgor. Mild jaundice. Spider angiomata present. Hair and nails
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. External hemorrhoids present. Stool brown; no
occult blood.
What is the suspected diagnosis, and what are the next steps in management?
116
II—CCS CASES BY CHIEF COMPLAINT
Case #47: Hepatic Encephalopathy
Keys to Diagnosis
n
n
n
ook for a patient with altered mental status or coma who has a known history of liver disL
ease or cirrhosis. Precipitating factors for encephalopathy include infection, new ­medication,
GI bleed, and renal failure.
On exam, there may be features of cirrhosis: skin exam with jaundice or spider angiomata,
rectal exam with hemorrhoids, and genitalia exam with testicular atrophy.
Diagnosis is based on history, ammonia level, and ruling out other causes such as brain
­lesions. In addition, look for precipitating causes such as toxins and infections.
Management
n
n
n
BCs—depending on severity of stupor, oxygen, intubation.
A
Reduce ammonia levels: lactulose, neomycin.
Mannitol if cerebral edema present.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Skin, HEENT, Heart,
•CBC
Lungs, Abdomen, Neuro
•Head CT
•Ammonia, blood
•PT/PTT
•LFT
•Toxicology screen, urine
•BMP
•Urine culture
•Urinalysis
•Blood culture
•ABG
•Thiamine, therapy
•Oxygen
•Lactulose, oral
•Consult, gastroenterology
•Neomycin, oral
•Intravenous access
•Cancel any precipitating medications
•Normal saline, 0.9% NaCl
•Pulse oximetry
•Foley catheter
•Blood pressure monitor
•Urine output
•Cardiac monitor
•From emergency department, transfer to ICU or ward depending on level of
coma.
•Management should be instituted within 4 hours of simulated time.
Orders
Exam
Orders
Clock
Orders
Location
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
Complete
Thiamine, Ammonia level, CBC, BMP, LFT, ABG, Urinalysis,
Toxicology screen urine, Head CT
Advance to results of ammonia level.
Lactulose, Neomycin, Consult gastroenterology
Change to inpatient unit or ICU depending on level of acuity.
Advance to additional results and case end.
Counsel patient, Reassure patient
8—ALTERED MENTAL STATUS
117
Case #48
Location: Emergency Department
Chief Complaint: Altered mental status and jaundice
Case introduction
Initial vital signs
Initial history
•A 41-year-old white woman is brought to the emergency department by her
sister for a 2-day history of jaundice and confusion.
•Temperature: 38.6 degrees C (101.5 degrees F)
•The patient has had a 2-day history of increasing fatigue, with her sister noticing increasing yellowness of her skin. In the past day, she has had increasing
confusion with difficulty finding words and expressing her thoughts. The patient had an upper respiratory tract infection 1 week ago. There is no history
of diarrhea, constipation, chest pain, shortness of breath, or cough.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed; patient lying in bed; in no apparent distress.
Skin
Yellow tinge to skin. Petechiae on legs and arms. Normal turgor. No nodules or
other lesions. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes with scleral icterus. Funduscopic
examination normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth
normal. Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
118
II—CCS CASES BY CHIEF COMPLAINT
Case #48: Thrombotic Thrombocytopenic Purpura (TTP)
Keys to Diagnosis
n
n
n
Patients typically present with nonspecific neurologic symptoms, jaundice, bleeding, and/
or purpura. Look for a precipitating factor, such as new medication, infection, pregnancy, or
malignancy.
Exam may show jaundice, pallor, purpura, or mucosal bleeding.
Diagnosis is based on evaluating for the classic pentad: (1) purpura with CBC showing
thrombocytopenia, (2) neurologic abnormalities, (3) fever, (4) renal disease, and (5) microangiopathic hemolytic anemia (CBC with anemia and schistocytes and laboratory evidence of
hemolysis—increased reticulocytes, bilirubin, LDH, or decreased haptoglobin). Order labs
to rule out DIC—PT/PTT, fibrin degradation products.
Management
n
n
n
Cancel any precipitating medications.
Plasma exchange.
Consult hematology; monitor abnormal values after plasma exchange.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Skin, HEENT, Abdomen, Neuro •PT/PTT
•CBC
•Fibrin degradation products
•BMP
•D-dimer
•Reticulocytes
•Direct Coombs’ test
•LFT
•hCG, beta, urine, qualitative
•Haptoglobin
•Urinalysis
•Plasma exchange (plasmapheresis)
•Intravenous access
•Consult, hematology/oncology
•Pulse oximetry
•Cardiac monitor
•CBC
•Blood pressure monitor
•Transfer to inpatient unit or ICU for monitoring.
•Management should be instituted within the first day of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
End Orders
Pulse oximetry
General, Skin, HEENT, Lung, Heart, Abdomen, Extremities, Neuro
CBC, BMP, LFT, Haptoglobin, PT/PTT, D-dimer, Urinalysis
Advance to CBC results.
Reticulocytes, Direct Coombs’, Fibrin degradation products
Advance to additional results.
Plasma exchange, Consult hematology
Change to inpatient unit or ICU.
Advance to additional results, patient updates and case end.
CBC daily
8—ALTERED MENTAL STATUS
119
Case #49
Location: Emergency Department
Chief Complaint: Medication overdose
Case introduction
Initial vital signs
Initial history
•A 31-year-old woman is brought to the emergency department by ambulance
after being found at home by her mother, having overdosed on Tylenol tablets.
•Pulse: 118 beats/min
•Blood pressure, systolic: 108 mm Hg
•Blood pressure, diastolic: 74 mm Hg
•The patient was found by her mother at home with an empty bottle of Tylenol
tablets near her bed. She is estimated to have ingested the tablets approximately 8 hours before arrival. The patient is known to have a history of depression and previous suicide attempts. The patient complains of nausea and had
two episodes of vomiting before arrival in the emergency department. She has
mild right upper quadrant abdominal pain.
•Past medical history of depression with three previous suicide attempts.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
99% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. Mild upper right tenderness. Liver and
spleen not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
120
II—CCS CASES BY CHIEF COMPLAINT
Case #49: Acetaminophen Overdose
Keys to Diagnosis
n
n
n
Typically, a history of acetaminophen use or overdose is generally provided. Look for a
­patient who either took an intentional overdose or has a history of cirrhosis. Symptoms
include right upper quadrant pain, nausea, vomiting, and anorexia. Vital signs may show
tachycardia and hypotension.
Exam may show evidence of jaundice or abdominal tenderness.
Serum acetaminophen level is elevated. Order baseline ECG, LFT, ABG, BMP, and
Urinalysis, hCG (if female).
Management
n
n
n
Nasogastric tube may reveal pill fragments.
N-acetylcysteine for prevention and treatment of hepatotoxicity.
Counsel and consult psychiatry.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, HEENT, Chest, Heart, Neuro •hCG, beta, urine, qualitative
•Acetaminophen toxicity nomogram
(if female)
•LFT
•Urinalysis
•BMP
•Toxicology screen, urine
•ABG
•N-acetylcysteine
•Oxygen
•Consult poison control center
•Normal saline, 0.9% NaCl
•Consult, substance abuse unit
•Intravenous access
•Consult, psychiatry
•Nasogastric tube
•Pulse oximetry
•Blood pressure monitor
•Cardiac monitor
•Admit to ward or ICU, depending on level of acuity.
•Management should be instituted within the first 2 hours of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Location
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor,
General, Skin, HEENT, Lung, Heart, Abdomen, Extremities, Neuro
Oxygen, Intravenous access, Normal saline 0.9% NaCl, nasogastric
tube, Acetaminophen toxicity nomogram, LFT, BMP, ABG,
Urinalysis, Toxicology screen, urine
Advance to acetaminophen results.
N-acetylcysteine, Consult poison control center, Consult substance
abuse unit, Consult psychiatry
Advance to next available set of results.
Change to ICU or inpatient unit, depending on need.
Advance to additional results, patient updates, and case end.
Counsel patient, Reassure patient
8—ALTERED MENTAL STATUS
121
Case #50
Location: Office
Chief Complaint: Pain and loss of vision in eye
Case introduction
Initial vital signs
Initial history
•A 37-year-old white woman presents to the office for a 3-day history of eye
pain and intermittent loss of vision in her right eye.
•Unremarkable.
•The patient experienced pain in her right eye beginning about 3 days ago.
The pain occurred predominantly with movement of the eye. Yesterday she
had two episodes of loss of vision in the right eye lasting approximately 15
minutes. Her vision now appears to be normal. In addition, she describes
increasing fatigue over the past 6 months. About 3 months ago, she experienced urinary urgency, frequency, and incontinence that lasted about 4
days. She is sexually active only with her husband of 10 years. She does not
smoke, drink, or use illicit drugs.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
HEENT/Neck
Normocephalic. Visual acuity decreased in right eye. Funduscopic examination
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Neuro/Psych
Mental status normal. Decreased sensation and reduced power of the right foot.
Cerebellar function normal. Deep tendon reflexes hyperreactive in the right foot.
What is the suspected diagnosis, and what are the next steps in management?
122
II—CCS CASES BY CHIEF COMPLAINT
Case #50: Multiple Sclerosis
Keys to Diagnosis
n
n
n
Look for a young, usually female patient with a history of neurologic symptoms over months
or years. Symptoms include visual disturbances (optic neuritis—pain or loss of vision in one
eye), gait abnormalities, sensory problems, motor problems, autonomic problems (bladder
dysfunction, constipation, sexual dysfunction), weakness, and fatigue.
On exam, may see unilateral visual changes in acuity or funduscopy and possible neurologic
findings (hyperreflexia, weakness, sensory disturbance).
Diagnosis is based on revised McDonald criteria (2010): combination of clinical findings,
brain MRI, and may need CSF studies and visual evoked potentials. Blood studies rule out
other potential causes.
Management
n
n
n
Disease-modifying therapy: interferon-beta 1a, SC (monitor CBC, LFT), or fingolimod,
oral.
Consult neurology, counseling.
Methylprednisolone IV for acute relapses.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Neuro ± Others
•Brain MRI
•CSF immunoelectrophoresis
•Visual evoked potentials
•Exam: additional ± complete
•CSF myelin basic protein
•CBC
•BMP
•TSH
•LFT
•Vitamin B12, serum
•ANA, serum
•Interferon-beta 1a
•Reassure patient
•Counsel patient
•Consult, neurology
•Monitor CBC, LFT for some medications.
•Unless acute disability, can treat as outpatient.
•Management should be instituted within a 4 days of simulated time; time course
of this case may last several weeks to months.
Exam
Orders
Clock
Orders
Clock
End Orders
Complete
Brain MRI, CSF immunoelectrophoresis, Visual evoked potentials,
CBC, BMP, TSH, LFT, vitamin B12 serum, ANA serum
Advance clock to reschedule patient when all results are reported.
Interferon, Counsel patient, Reassure patient, Consult neurology
Advance to additional patient updates and case end.
CBC, LFT in 1 month
123
8—ALTERED MENTAL STATUS
Altered Mental Status—Key Points
n
n
or patients who present in coma, the majority of cases can be diagnosed on history, exam,
F
and initial workup. Table 8-1 lists basic features to help separate the most common diagnoses. All patients should be treated with ABCs and supportive measures in addition to the
treatments listed.
For patients that present with altered mental status, consider the following tests to help aid
in the diagnosis:
n F ingerstick glucose
n ECG, 12-lead
n ABG
n Head CT without contrast
n Urinalysis
n Urine culture
n Blood culture
n Ammonia
n CBC
n V itamin B12, serum
n BMP
n Depression index
n Toxicology screens
TABLE 8-1
n
Diagnosis
Vital signs
Exam
Diagnostic Studies
Treatment
Tricyclic
antidepressant
overdose
Tachycardia
Bradypnea
Hypotension
ECG shows QRS
prolongation
Sodium
bicarbonate
Benzodiazepine
overdose
Bradypnea
Hypotension
ECG, CT to
rule out other
diagnoses
Flumazenil
Opioid overdose
Bradycardia
Bradypnea
Hypotension
Hypertension
Dilated pupils
(mydriasis)
Absent bowel
sounds
Vertical
nystagmus
Diminished
reflexes
Constricted pupils
(miosis)
ECG, CT to
rule out other
diagnoses
Naloxone
Funduscopy shows
papilledema
and retinal
hemorrhages
Head CT is
diagnostic
Labetalol
Subarachnoid
hemorrhage
C H A P T E R
9
Pain in the Extremities
Key Orders*
Order
CCS Terminology
Chest X-ray, PA/lateral
Urinalysis
Arthrocentesis
CBC with differential
PT/PTT
BMP
D-dimer, plasma
Wrist, X-ray
Knee, X-ray
Pelvic, X-ray, portable
Synovial fluid, Gram stain
Amylase, serum
ESR
LFT
Lipase, serum
Skeletal survey
Duplex scan, leg, venous
Synovial fluid, cell count
Synovial fluid, crystals
Uric acid, blood
Synovial fluid, glucose
Synovial fluid analysis
Synovial fluid, culture
X-ray, chest, PA/lateral
Urinalysis
Arthrocentesis
CBC with differential
PT/PTT
Basic metabolic profile
D-dimer, plasma
X-ray, wrist
X-ray, knee
X-ray, pelvis, portable
Gram stain, synovial fluid
Amylase, serum
Sedimentation rate, erythrocyte
Liver function panel
Lipase, serum
Osseous survey
Doppler, lower extremities, venous
Cell count, synovial fluid
Crystals, synovial fluid
Uric acid, serum
Glucose, synovial fluid
Synovial fluid analysis
Bacterial culture, synovial fluid
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
ED Setting (Stat)
20 min
20 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
40 min
60 min
90 min
2 hr
2 hr
2 hr
2 hr
2 hr 20 min
2 hr 20 min
3 hr
3 hr 20 min
5 hr 20 min
30 hr 20 min
9—PAIN IN THE EXTREMITIES
125
Case #51
Location: Emergency Department
Chief Complaint: Wrist pain
Case introduction
Initial vital signs
Initial history
•A 3-year-old boy is brought to the emergency department by his mother and
stepfather for pain in the right wrist after a fall.
•Unremarkable
•The mother says the patient slipped and fell down the stairs about 3 hours ago.
She decided to bring him in when the pain did not go away and he had difficulty
using his right hand. He did not hit his head or have any loss of consciousness.
The stepfather has been angry at nursing staff and demanding the patient be
seen quickly so they can go home.
•Past medical history of three emergency department visits for falls and injuries in
the past year.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin child holding his right wrist in discomfort.
Skin
Bruises of varying ages on the back, legs, and abdomen. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Chipped tooth in the mouth. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall with multiple bruises. Diaphragm and chest move equally and
symmetrically with respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bruising on the abdomen of varying ages. Bowel sounds normal; no bruits. No
masses or tenderness. Liver and spleen not palpable. No hernias.
Extremities/Spine
Tenderness and swelling at the right wrist with reduced range of motion. Peripheral
pulses normal. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
126
II—CCS CASES BY CHIEF COMPLAINT
Case #51: Child Abuse
Keys to Diagnosis
n
n
n
Look for a child who presents with trauma, injury, or bruising. The case may begin with a
history of fall. Often, there is a history of previous visits to the ED for injuries. Also, look for
the child to be accompanied by an uncooperative or argumentative parent or guardian.
On examination, look for evidence of previous or characteristic injuries: chipped tooth,
healed bruises, or injuries in multiple locations.
Imaging with skeletal survey may reveal previous healed fractures. For bruising, rule out a
coagulation disorder with CBC and PT/PTT.
Management
n
n
n
Treat any acute injuries—pain relief, cast for fractures.
Admit child to the inpatient unit for safety.
Social worker consult, counsel, reassure.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Skin, Genitalia, Extremities
•LFT
•CBC
•Amylase
•PT/PTT
•Lipase
•Skeletal survey
•Urinalysis
•X-ray of injured extremity
•Consult, social services
•Counsel parent
•Acetaminophen, oral, continuous
•Reassure patient
•Cast extremity (if fracture)
•Not important for this case
•Admit to inpatient unit for patient safety.
•Management should be instituted within 4 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Location
Clock
End Orders
Complete
CBC, PT/PTT, Skeletal survey, X-ray of extremity, LFT,
Amylase, Lipase, Urinalysis, Acetaminophen
Advance clock to skeletal survey.
Cast extremity (if fracture), Consult social services, Counsel
patient/family, Reassure patient
Advance to consult.
Change to inpatient unit.
Advance to additional updates and case end.
None
9—PAIN IN THE EXTREMITIES
127
Case #52
Location: Emergency Department
Chief Complaint: Knee pain and swelling
Case introduction
Initial vital signs
Initial history
•A 49-year-old African-American man is brought to the emergency department by
his wife for right knee pain and swelling that began 4 hours ago.
•Temperature: 38.2 degrees C (100.8 degrees F)
•The patient has been having increasing pain and swelling in his right knee over
the past 4 hours. The pain is sharp and constant. He has difficulty walking and
bending his right knee. There is no history of injury to the area. He has had mild
episodes of pain in this joint before, but they have typically resolved on their own
and have never been this severe. He does not have any pain in other joints. He is
sexually active only with his wife of 25 years. He does not smoke, drink alcohol,
or use illegal drugs.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding his right knee in pain.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities
Right knee with swelling and limited range of motion. Left knee and other joints
normal. Peripheral pulses normal. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
128
II—CCS CASES BY CHIEF COMPLAINT
Case #52: Gout
Keys to Diagnosis
n
n
n
Look for sudden onset of pain or swelling in one joint—knee, toe, wrist, ankle, or elbow.
Typically, there is a history of joint pain that resolves. There may be a low-grade fever on vital
signs.
On exam, look for a unilateral red, swollen joint. Tophi may be seen in the extremities.
Synovial fluid crystal exam is diagnostic. Also, order evaluation for septic arthritis. Imaging
studies can have characteristic features but are not diagnostic. Baseline labs before starting
treatment are generally recommended, particularly looking at renal function.
Management
n
n
n
Acute gout can be treated with NSAIDs (e.g., indomethacin), colchicine, intra-articular steroids (e.g., triamcinolone), or oral steroids (e.g., prednisone). Avoid NSAIDs and use steroid
if history of renal insufficiency or peptic ulcer.
Allopurinol is used several weeks after acute attack.
Counseling, diet low in purine and fat, avoid alcohol.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Extremities, Neuro
•X-ray (of affected joint)
•Arthrocentesis
•CBC with differential
•Synovial fluid, Gram stain
•LFT
•Synovial fluid, crystals
•Uric acid, serum
•Synovial fluid, cell count
•Urinalysis
•Synovial fluid, culture
•BMP
•Medication (NSAID, colchicine, or steroid)
•Allopurinol after several weeks
•Advise patient, side effects of medication
•Advise patient, no alcohol
•Monitor uric acid every 1–2 months after allopurinol is started.
•Admit to inpatient unit for acute flare.
•Management should be instituted within 1 day of simulated time.
Exam
Location
Orders
Clock
Orders
Clock
End Orders
General, Lymph nodes, Extremities + Others
Change to inpatient unit.
X-ray of affected joint, Arthrocentesis, Synovial fluid studies
(crystals, gram stain, cell count, culture), CBC, BMP, LFT,
Uric acid, Urinalysis
Advance clock to results of synovial fluid studies.
Medication (NSAID, colchicine, or steroid), Counsel patient,
Advise patient no alcohol
Advance clock to additional results, patient updates, and
case end.
Allopurinol in several weeks
9—PAIN IN THE EXTREMITIES
129
Case #53
Location: Emergency Department
Chief Complaint: Hip pain following a fall
Case introduction
Initial vital signs
Initial history
•A 91-year-old woman is brought to the emergency department for right hip pain
after a fall at home
•Blood pressure, systolic: 110 mm Hg
•Blood pressure, diastolic: 65 mm Hg
•The patient fell at home on a loose rug in her bedroom. She hit the side of her
bed and the floor with her right hip. She was unable to get up after falling and
describes severe pain in the right hip rated 8 on a 10-point scale. She did not hit
her head or lose consciousness. She is normally in good health and lives with her
daughter.
•Past medical history of osteoarthritis and osteoporosis.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Elderly, thing woman lying in bed in moderate distress holding her right hip.
Skin
Normal turgor. Mild bruising at the right hip. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Extremities
Right leg shortened and externally rotated compared with left leg and has
reduced range of motion. Peripheral pulses weak. Spine examination results
normal.
What is the suspected diagnosis, and what are the next steps in management?
130
II—CCS CASES BY CHIEF COMPLAINT
Case #53: Femoral Neck Fracture
Keys to Diagnosis
n
n
n
Look for an older patient who presents with hip pain after a fall and is unable to ambulate.
Vital signs may show hypotension.
Exam may show affected limb is shortened with reduced motion.
Pelvis X-ray is diagnostic for fracture. Watch for underlying disease that may have precipitated the fall, such as myocardial infarction, COPD, or TIA.
Management
n
n
n
Surgery with orthopedic consult.
Pain relief with morphine.
Treat any associated diagnoses.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Chest, Heart, Extremities
•Pelvis X-ray, portable
THERAPY
•CBC
•PT/PTT
•BMP
•ECG, 12 lead
•Troponin I x3
•Type and crossmatch, blood
MONITORING
LOCATION
TIMING
•Consult, orthopedic surgery
•Morphine
•Blood pressure monitor if hypotension.
•Patient may be taken to surgery, otherwise admit to ICU.
•Management should be instituted within 2 hours of simulated time.
SEQUENCING
Orders
Blood pressure monitor, Pulse oximetry, Cardiac monitor
Exam
Orders
Clock
Orders
General, Chest, Heart, Extremities ± Others
Pelvis X-ray, Intravenous access, Normal saline, Morphine
Advance to results of X-ray.
Consult orthopedic surgery, CBC, PT/PTT, BMP, Type and
crossmatch blood, ECG, Troponin
Advance to consult result.
Change to ICU.
Advance to additional results and case end.
None
Clock
Location
Clock
End Orders
9—PAIN IN THE EXTREMITIES
131
Case #54
Location: Inpatient Unit
Chief Complaint: Leg pain
Case introduction
Initial vital signs
Initial history
•You are called to see a 63-year-old woman in the inpatient unit for leg pain that
began 2 hours ago.
•Unremarkable
•The patient describes pain located at the right calf and behind the right knee.
The pain is sharp, constant, and rated 5 on a 10-point scale. There is no shortness of breath, chest pain, or shaking chills. The patient was admitted 3 days
ago after a motor vehicle accident in which she suffered abdominal trauma and
she underwent splenectomy. She did have bruising to her legs but no fractures.
Since the operation, she has been lying in bed with little activity.
•Past medical history of lung cancer treated with surgery and chemotherapy 1
year ago, now in remission.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding her right knee and calf in moderate
distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Extremities
Swelling and tenderness at the right calf. Pain is worse with dorsiflexion of the
right foot. The left leg is unremarkable. Peripheral pulses normal.
What is the suspected diagnosis, and what are the next steps in management?
132
II—CCS CASES BY CHIEF COMPLAINT
Case #54: Deep Vein Thrombosis (DVT)
Keys to Diagnosis
n
n
n
Look for an inpatient with pain and swelling in the leg. Risk factors include immobilization,
postoperative state, trauma, estrogens, cancer, pregnancy, obesity, and many others.
Extremities exam shows swelling and tenderness. Pain may be worse with dorsiflexion of foot
(Homan’s sign).
Diagnosis is made by ultrasound. D-dimer is elevated. Consider evaluation for pulmonary
emboli (chest CT).
Management
n
n
Anticoagulation: can use factor Xa inhibitor (e.g., fondaparinux, SQ) or low-molecular-weight heparin (e.g., enoxaparin, SQ) for 5 days along with warfarin (Coumadin). Use Inferior vena cava filter if contraindication to anticoagulation.
Counseling and reassurance.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Extremities, Chest, Heart
•CBC with differential
•D-dimer, plasma
•BMP
•PT/PTT
•Spiral CT Chest
•Duplex scan, leg, venous
•Anticoagulation (fondaparinux or
•Advise patient, no smoking
enoxaparin)
•Reassure patient
•Coumadin, oral continuous
•Advise patient, medication side effects
•PT/PTT
•If signs of PE or abnormal vitals, admit to ICU, otherwise continue
­management in the inpatient unit
•Management should be instituted within 2 hr of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
General, Chest, Heart, Extremities ± Others
CBC, BMP, PT/PTT, D-dimer, Duplex scan leg
Advance to duplex scan results.
Spiral CT chest, Anticoagulation (fondaparinux or LMWH),
Coumadin, Advise patient medication side effects
Advance clock to additional results, patient updates and case
end.
PT/PTT daily
9—PAIN IN THE EXTREMITIES
133
Case #55
Location: Emergency Department
Chief Complaint: Wrist pain
Case introduction
Initial vital signs
Initial history
•A 33-year-old white woman is brought to the emergency department by her
husband for wrist pain after a fall.
•Unremarkable
•The patient describes working in her garden and tripping over gardening
equipment, causing her to fall. She broke her fall with her right hand, and she
has been experiencing pain since the fall, which occurred 6 hours ago. The
pain is sharp, constant, and rated a 6 on a 10-point scale. She has had difficulty moving her wrist and using her right hand since the injury occurred. Her
husband is demanding you give her pain medications so they can go home.
•Past medical history of two visits to the emergency department in the past
year for falls and injuries.
•She smokes one pack of cigarettes a day and is a recovered IV drug user. She
has been married for 2 years and has no children.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, well-developed woman; holding her right wrist in pain.
Skin
Bruises of varying ages on the back. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Tenderness and swelling at the right wrist with reduced range of motion.
Peripheral pulses normal. Bruises of varying ages on her legs and back.
What is the suspected diagnosis, and what are the next steps in management?
134
II—CCS CASES BY CHIEF COMPLAINT
Case #55: Spousal Abuse
Keys to Diagnosis
n
n
n
Look for a patient who presents with an injury or bruise. Often, as a clue, a disruptive spouse
or boyfriend/girlfriend is present. Although more common to women, the victim of spousal
abuse may be a man.
Exam shows multiple injuries of varying stages of healing.
Social services consult may lead to the diagnosis if not initially obvious. For bruising, rule
out a coagulopathy.
Management
n
n
n
Treat injury: Cast if fracture present, pain relief with acetaminophen.
Counseling and reassurance. Consult social services and advise patient safety plan and
­restraining order.
Admit to inpatient unit for safety.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Extremities, HEENT, Skin
•X-ray of affected joint
THERAPY
•Exam: Additional
•CBC
•PT/PTT
•Counsel patient
•Advise patient, restraining order
•Reassure patient
•Acetaminophen
•Cast extremity (if fracture)
•Consult, social services
•Advise patient, safety plan
•Advise patient, no smoking
•Not important for this case
•Admit to inpatient unit for patient safety.
•Management should be instituted within 4 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Location
Clock
End Orders
General, Skin, HEENT, Abdomen, Genitalia, Extremities ± Others
CBC, PT/PTT, X-ray of affected joint, Acetaminophen
Advance to results.
Cast extremity (if fracture), Consult social services, Counsel
patient, Advise patient safety plan, Advise patient restraining
order, Reassure patient, Advise patient no smoking
Change to inpatient unit.
Advance to patient updates and case end.
None
9—PAIN IN THE EXTREMITIES
135
Case #56
Location: Emergency Department
Chief Complaint: Knee pain
Case introduction
Initial vital signs
Initial history
•A 29-year-old Latino woman is brought to the emergency department by her
boyfriend for pain in her left knee that began 6 hours ago.
•Temperature: 38.4 degrees C (101.1 degrees F)
•Pulse: 122 beats/min
•Respiratory rate: 31/min
•The patient describes pain and swelling in her left knee that began 6 hours ago
and has progressively worsened. The symptoms began as a vague ache in her
left knee that progressed to severe pain, swelling, and warmth with impairment
of joint function. The pain is rated 8 on a 10-point scale. She has not had any
trauma to the joint and has not had symptoms in the past. She had one episode
of shaking chills 1 hour ago. She has not experienced shortness of breath, chest
pain, or vaginal discharge.
•Past medical history of gonococcal cervicitis 6 months ago.
•Social history includes smoking one-half pack of cigarettes a day, occasional
alcohol use, and use of intravenous heroin over the past year. She is sexually
active with two men and occasionally uses condoms for contraception.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding her left knee in pain.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Extremities/Spine
Left knee with swelling, tenderness warmth and reduced range of motion. Right
knee and other joints normal. Peripheral pulses normal.
What is the suspected diagnosis, and what are the next steps in management?
136
II—CCS CASES BY CHIEF COMPLAINT
Case #56: Septic Arthritis
Keys to Diagnosis
n
n
n
Look for a patient who presents with acute-onset swelling, pain, and tenderness in a joint.
Often a history of chills is present. If the patient is a young, sexually active adult, consider
gonococcal arthritis. Vitals may show fever or other signs of sepsis.
On exam, the affected joint is swollen, warm, and tender
Diagnosis is made by synovial fluid exam showing high white blood cell count and no
­crystals. Gram stain may identify the organism. Order X-ray to rule out osteomyelitis.
Management
n
n
n
Acute treatment is with antibiotics based on Gram stain results. For gram-positive cocci, use
nafcillin or vancomycin if MRSA is suspected. For gram-negative rods or gonococcal infection, use third-generation cephalosporin (e.g., ceftriaxone).
Immobilize joint and aspirate joint daily. Consult orthopedics for potential surgical ­drainage.
Pain relief with morphine.
Treat in the inpatient unit. Consult physical therapy.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Skin, Lymph Nodes,
•CBC with differential
Extremities
•PT/PTT
•X-ray of affected joint
•BMP
•Arthrocentesis
•Urinalysis
•Blood cultures
•hCG, beta, urine, qualitative (if female)
•Synovial fluid, Gram stain
•Synovial fluid, crystals
•Synovial fluid, culture and
sensitivity
•Synovial fluid, cell count
•Antibiotic therapy (e.g.,
•Consult, orthopedic surgery
ceftriaxone or vancomycin)
•Intravenous access
•Immobilize joint
•Normal saline, 0.9% NaCl
•Aspirate joint fluid
•Morphine
•Vital signs as appropriate
•Treat in the inpatient unit.
•Management should be instituted within 2 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Location
Clock
End Orders
General, Skin, Lymph Nodes, Chest, Heart, Extremities, Neuro
Arthrocentesis, Synovial fluid studies (gram stain, crystals, cell
count, culture), CBC, PT/PTT, BMP, Blood culture, X-ray of
affected joint
Advance to results of gram stain.
Antibiotic therapy (e.g., ceftriaxone; or see above), Immobilize
joint, Consult orthopedic surgery, Aspirate joint fluid, Morphine
Advance to additional results.
Change to inpatient unit.
Advance to additional results, patient updates and case end.
Aspirate joint fluid daily
9—PAIN IN THE EXTREMITIES
137
Pain in the Extremities—Key Points
n
n
e on the lookout for abuse presenting as pain in an extremity after a fall. Child abuse,
B
spousal abuse, and elder abuse can all present with injury or pain in an extremity.
Important orders to keep in mind for pain in an extremity or joint include:
n Arthrocentesis
n Synovial fluid, Gram stain
n Synovial fluid, cell count
n Synovial fluid, crystals
n Synovial fluid, culture
n X-ray of the extremity
n D-dimer, plasma
n ESR
n Skeletal survey
n D uplex scan, leg, venous
n Rheumatoid factor
n ANA, serum
C H A P T E R
10
Cough
Key Orders*
Time to Results—ED
Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor,
continuous
Cardiac monitor
Peak flow
Chest X-ray, portable
ABG
Chest X-ray, PA/lateral
HIV rapid antibody test, blood
Sputum Gram stain
Sputum fungal stain
Chest CT scan with contrast
Neck X-ray, soft tissue
Mediastinal lymph node biopsy
Sputum AFB smear
Bronchoscopy (Automatic
Consult pulmonary medicine)
Laryngeal biopsy, by direct
laryngoscopy
Sputum PCR, mycobacterial
RNA
Sputum cytology
Sputum pneumocystis stain
HIV test, ELISA, serum
Sputum culture
PPD
Sputum fungal culture
HIV test, p24 antigen, serum
HIV viral load
Pulse oximetry
Monitor, continuous blood
pressure cuff
Monitor, cardiac
Peak flow
X-ray, chest, AP, portable
Arterial blood gases
X-ray, chest, PA/lateral
Antibody, rapid HIV test, blood
Gram stain, sputum
Fungal stain, sputum
CT, chest, with contrast
X-ray, neck, soft tissue
Mediastinoscopy
Acid fast stain, sputum
Bronchoscopy
1 min
5 min
Laryngoscopy, direct
1 hr 15 min
Polymerase chain reaction, TB
RNA, sputum
Cytology, sputum
Pneumocystis stain, sputum
Antibody, HIV, ELISA, serum
Bacterial culture, sputum
Skin test, tuberculin
Fungal culture, sputum
Antigen, P24-, HIV, serum
Polymerase chain reaction, HIV
DNA, blood
HIV genotype, blood
Mycobacterial culture, sputum
24 hr
HIV genotype, blood
Sputum, mycobacterial culture
5 min
5 min
10 min
18 min
20 min
20 min
20 min
30 min
30 min
30 min
1 hr
1 hr
1 hr 15 min
24 hr
24 hr
24 hr
30 hr
2 days
4 days
4 days
7 days
7 days
42 days
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
139
10—COUGH
Case #57
Location: Emergency Department
Chief Complaint: Cough and wheezing
Case introduction
Initial vital signs
Initial history
•A 19-month-old boy is brought to the emergency department by his parents
for cough and wheezing for the past 4 hours.
•Respiratory rate: 24/min
•The patient developed sudden onset of cough and wheeze while unattended
at a birthday party. He has never experienced these types of symptoms in
the past. The parents became worried when the symptoms did not resolve
and continued for several hours. He has not complained of any pain, and the
cough is not associated with sputum.
•Past medical history includes eczema as an infant. All vaccinations are up to
date.
•Family history, developmental history, and review of systems are un­
remarkable.
INITIAL MANAGEMENT
Orders
Exam
•Pulse oximetry
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Active child, occasional coughing spells in no acute distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. Loud expiratory wheeze predominantly in the left lower
lung.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
140
II—CCS CASES BY CHIEF COMPLAINT
Case #57: Foreign Body Aspiration
Keys to Diagnosis
n
n
n
ook for a small child with acute-onset cough and wheeze while unattended. Other
L
symptoms may include chest pain and shortness of breath. Vitals may show a low-grade
fever.
On lung exam, look for fixed, localized wheeze, and decreased breath sounds.
Bronchoscopy is both diagnostic and therapeutic. Imaging studies, such as chest X-ray, may
show overinflation, atelectasis, or pneumonia or can be normal.
Management
n
n
n
ronchoscopy for removal of aspirated object (often a peanut or pistachio).
B
If the foreign body is quickly removed, the patient is asymptomatic, and no complications are
seen, inpatient care is generally not needed. However, observation for 1 to 2 days postextraction is generally advised.
Counseling and reassurance.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Lungs
THERAPY
•Exam: Additional
•Chest X-ray, PA/lateral
•Reassure patient
•Counsel patient/family
•Oxygen
•Bronchoscopy
•Pulse oximetry
•Admit to inpatient unit for observation after the foreign body has been
removed.
•Bronchoscopy should be ordered within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
End Orders
Pulse oximetry
General, Heart, Lungs, HEENT, Abdomen, Skin,
Extremities
Chest X-ray PA/lateral, Oxygen
Advance to results.
Bronchoscopy
Advance to results.
Vital signs, Reassure patient, Counsel patient/family
Change to inpatient unit.
Advance to patient updates and case end.
None
141
10—COUGH
Case #58
Location: Office
Chief Complaint: Cough with shoulder pain
Case introduction
Initial vital signs
Initial history
•A 58-year-old African-American man arrives at the office for a 2-month history
of cough.
•Temperature: 38.6 degrees C (101.5 degrees F)
•The patient has experienced intermittent coughing for the past 2 months associated with yellow sputum and mild dyspnea. Over the past week, he has been experiencing worsening shoulder pain. He has not experienced chest pain, shaking
chills, or night sweats. He has had a 15-lb weight loss over the past 3 months.
•Past medical history includes COPD.
•Social history includes smoking one pack of cigarettes a day for the past 30 years.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, male; well developed; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Decreased breath sounds in the right base.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
142
II—CCS CASES BY CHIEF COMPLAINT
Case #58: Lung Cancer
Keys to Diagnosis
n
n
n
Patients often present with cough, shortness of breath, weight loss, fatigue, or unusual symptoms (e.g., shoulder pain). Often, an associated pneumonia will be present with yellow sputum and fever. Intrathoracic spread of the tumor may present as hoarseness, dysphagia, or
stridor. If SIADH is present, look for symptoms of hyponatremia (anorexia, nausea, malaise,
muscle cramps, weakness, headache, or irritability).
Exam may show features of pneumonia (rales, rhonchi, wheeze, dullness to percussion).
Chest X-ray, PA/lateral will provide the first clues to an abnormality. Sputum culture and
cytology may provide additional information. Chest CT should be performed for diagnostic
and staging purposes. A bronchoscopy or mediastinoscopy with cytologic evaluation may be
needed for diagnosis.
Management
n
n
n
n
Consult surgery, hematology/oncology, and radiation therapy. Counseling regarding cancer
diagnosis.
Staging studies include CBC, BMP, LFT, MRI brain (for metastases), bone scan, and bone
marrow biopsy.
Demeclocycline and fluid restriction if SIADH and hyponatremia is present associated with
small cell carcinoma.
Pneumonia should be managed with antibiotics (e.g., levofloxacin).
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Chest X-ray, PA/lateral
•Pulse oximetry
•Chest CT scan with contrast
•CBC
•Bronchoscopy
•BMP
•Sputum Gram stain
•Abdominal CT scan with contrast
•Sputum culture
•LFT
•Sputum cytology
•Brain MRI
•Advise patient, cancer diagnosis
•Consult, radiation therapy
•Consult, hematology/oncology
•Consult, thoracic surgery
•Antibiotics (if pneumonia)
•Reassure patient
•Advise patient, fluid restriction (if SIADH)
•Advise patient, advance directive
•Demeclocycline (if SIADH)
•Not important for this case unless vital signs abnormal.
•Manage in inpatient unit if pneumonia, SIADH, or other complications present.
•Diagnosis and management should be instituted within 2 days of simulated
time.
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Heart, Lungs, Lymph nodes, Extremities ± Additional
Pulse oximetry, CXR PA/lateral
Advance clock to results of X-ray.
Inpatient unit
Sputum Gram stain, Sputum culture, Sputum cytology, Chest CT
scan with contrast, Bronchoscopy, Antibiotic, Acetaminophen,
Advise patient no smoking, Advise patient side effects of
medication, Counsel patient
Advance to results of bronchoscopy or sputum cytology.
Advise patient cancer diagnosis, Abdominal CT scan with contrast,
CBC, BMP, LFT, Consult hematology/oncology, Consult radiation
therapy, Consult thoracic surgery, Reassure patient
Advance to additional results and case end. Treat SIADH and
hyponatremia if present.
Advise patient advance directive.
143
10—COUGH
Case #59
Location: Office
Chief Complaint: Cough and shortness of breath
Case introduction
Initial vital signs
Initial history
•A 30-year-old white woman arrives at the office for a 2-week history of cough
and shortness of breath.
•Temperature: 39.1 degrees C (102.4 degrees F)
•The patient has experienced a worsening cough over the past 2 weeks. The
cough is generally dry but occasionally associated with small amounts of
white sputum. She has also experienced increasing shortness of breath on
exertion over the past week. She has experienced shaking chills and night
sweats over the past 2 days. She has not experienced chest pain, diarrhea,
dysuria, or vaginal discharge.
•Past medical history of chlamydia treated 2 years ago.
•Social history shows the patient is bisexual and previously worked as a prostitute. She used to be an IV heroin drug user but quit 6 months ago.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities,
Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin woman with mild shortness of breath.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae,
external auditory canals, and tympanic membranes, normal. Mouth
with white spots on tongue and gums. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. Mild crackles and rhonchi bilaterally.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous distention.
Blood pressure equal in both arms.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon
reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
144
II—CCS CASES BY CHIEF COMPLAINT
Case #59: Pneumocystis carinii Pneumonia/AIDS
Keys to Diagnosis
n
n
n
The most common symptoms of PCP pneumonia are nonproductive cough, fever, and shortness of breath on exertion. Additional symptoms include chills and weight loss. In the setting
of AIDS, look for additional abnormalities, such as oral or vaginal thrush, lymphadenopathy
from lymphoma, diarrhea, chills, or night sweats. Look for HIV risk factors such as multiple
sexual partners, prostitution, or IV drug use.
On exam, look for lymphadenopathy, thrush on oral or vaginal exam, and evidence of pneumonia on lung exam.
Diagnose HIV by rapid test and ELISA. Obtain CD4 count. Culture any possible infection
sources—sputum, genitalia, stool. Biopsy any significant lymphadenopathy.
Management
n
n
n
n
Diagnosis and management should be performed in the inpatient unit.
Start antiretroviral therapy—two nucleoside reverse transcriptase inhibitors (nRTIs) and
a non-nucleoside reverse transcriptase inhibitor (NNRTI) (e.g., efavirenz, ­zidovudine,
­lamivudine).
Treat infections with antibiotics (TMP-SMZ for 21 days in PCP pneumonia).
Counseling and HIV support. Notify public health department.
DIAGNOSIS
THERAPY
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Chest X-ray, PA/lateral
•Sputum Gram stain
•Sputum Pneumocystis stain
•HIV rapid antibody test, blood
•HIV test, ELISA, serum
•CD4 cell count
•Antibiotics (TMP-SMZ for PCP)
•Antiretroviral therapy (e.g., efavirenz,
zidovudine, lamivudine)
•HIV support group
•Notify public health department
•CBC
•BMP
•LFT
•ABG
•Sputum fungal stain
•Sputum culture
•Advise patient, side effects of
medication
•Counsel patient
•Reassure patient
•Nystatin (if oral thrush)
•Vaccine, influenza
•Vaccine, pneumococcal
MONITORING
LOCATION
TIMING
•Pulse oximetry
•Initial diagnosis and management should occur in the inpatient unit.
•Management should be instituted within 1 day of simulated time.
SEQUENCING
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
Complete
Pulse oximetry, Chest X-ray PA/lateral, HIV rapid test
Advance clock to chest X-ray results.
Inpatient unit
HIV test ELISA, CD4 cell count, Sputum studies (gram stain,
pneumocystis stain, fungal stain, acid fast stain, culture),
CBC, BMP, LFT
Advance clock to additional results.
Antibiotics for any infections (Ex. TMP-SMZ), Antiretroviral
therapy, Advise patient side effects of medication, Counsel
patient, Reassure patient, HIV support group, Notify public
health department, Pneumococcal vaccine
Advance to additional results, patient updates and case end.
None
145
10—COUGH
Case #60
Location: Office
Chief Complaint: Cough
Case introduction
Initial vital signs
Initial history
•A 41-year-old man who recently immigrated from Guatemala presents
to the office with a 3-week history of cough.
•Temperature: 37.8 degrees C (100.1 degrees F)
•The patient describes his cough beginning about 3 weeks ago and
worsening over the past week. The cough is associated with yellow
sputum, and occasionally he has noticed blood in the sputum. He has
experienced mild chest pain associated with the coughing. He has
reduced energy and fatigue over the past 2 weeks, making working at
his construction job difficult. His appetite is reduced, and he notes an
11-lb weight loss over the past month. He has had night sweats and
shaking chills on two nights. No other members of the household have
symptoms.
•He has smoked one pack of cigarettes a day for the past 20 years. He
is married and does not drink alcohol or use illicit drugs.
•Family history and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin man; coughing but in no acute distress.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal.
Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. Rales and rhonchi present at the right apex.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No
edema. Peripheral pulses normal. No joint deformity or warmth; full
range of motion. Spine examination results are normal.
What is the suspected diagnosis, and what are the next steps in management?
146
II—CCS CASES BY CHIEF COMPLAINT
Case #60: Tuberculosis
Keys to Diagnosis
n
n
n
Patients typically present with cough, weight loss, fever, night sweats, or hemoptysis. Often
there is some risk factor in the history, such as immigration from an endemic area (Latin
America, Indian subcontinent, Africa, Southeast Asia), homelessness, or incarceration.
Exam may show rales or bronchial breath sounds.
Diagnosis is based on history, chest X-ray, sputum studies for mycobacteria, and PPD. HIV
testing should be performed on all new patients.
Management
n
n
n
Patients should be treated in the inpatient unit with reverse isolation until three sputum
smear results are negative.
Begin treatment after confirmation of mycobacteria is present either with acid-fast stain,
sputum TB PCR RNA, or PPD. Initial empiric treatment with the four-drug regimen of
isoniazid, rifampin, pyrazinamide, and ethambutol (or streptomycin). Order directly observed therapy. Monitor uric acid levels for pyrazinamide. Pyrazinamide and ethambutol can
be stopped at 2 months if TB isolate is susceptible and sputum study results are negative. For
isoniazid, monitor ALT and give pyridoxine.
Counseling and notify public health department.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Chest X-ray, PA/lateral
•Sputum AFB smear
•Sputum mycobacterial culture
•Sputum PCR, mycobacterial, RNA
•PPD
•HIV test, ELISA
THERAPY
•Sputum Gram stain
•Sputum culture
•Sputum cytology
•CBC
•BMP
•LFT
•Uric acid
•Advise patient, no smoking
•Advise patient, no alcohol
•Advise patient, side effects of
medication
•Reassure patient
•Counsel patient
•Isoniazid (+ Pyridoxine)
•Rifampin
•Pyrazinamide
•Ethambutol hydrochloride
•Reverse isolation
•Directly observed therapy
•Notify public health department
•Sputum AFB smear daily, TB PCR RNA at 1 and 2 months, Chest X-ray, PA/
lateral at 2 months
•The patient should be initially managed in the inpatient unit for isolation.
•Management should be instituted within the first day of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Chest ± Others
Chest X-ray, PA/lateral
Advance to results of chest X-ray.
Inpatient unit
Reverse isolation, Sputum studies (AFB smear, Mycobacterial
culture, PCR mycobacterial RNA, gram stain, culture, cytology),
PPD, CBC, BMP, LFT, Uric acid, HIV test ELISA
Advance to results of sputum studies.
Isoniazid, Rifampin, Pyrazinamide, Ethambutol hydrochloride,
Pyridoxine, Notify public health department, Directly observed
therapy, Reassure patient, Counsel patient, Advise patient no
alcohol, Advise patient side effects of medication, Advise patient
no smoking
Advance clock to additional results, patient updates and case end.
Sputum AFB smear daily
147
10—COUGH
Case #61
Location: Office
Chief Complaint: Cough and lymphadenopathy
Case introduction
Initial vital signs
Initial history
•A 44-year-old woman who recently arrived from India is brought to the
office by her husband for a 1-month history of cough.
•Unremarkable
•The patient has experienced a cough beginning 4 weeks ago. The cough
is not associated with sputum, and she has not experienced hemoptysis.
She has had three episodes of shaking chills and night sweats over the
past week. She has had one episode of mild shortness of breath with
exertion. She has noticed enlarged lumps in her neck, which are painless.
She has not experienced any chest pain. No other members of the household have symptoms. She is sexually active only with her husband of 15
years. She does not smoke, drink alcohol, or use illegal drugs.
•Past medical history of three childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin woman in no apparent distress.
Lymph nodes
Enlarged cervical lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
148
II—CCS CASES BY CHIEF COMPLAINT
Case #61: Hodgkin Lymphoma
Keys to Diagnosis
n
n
n
Look for a patient who presents with cough or shortness of breath related to a mediastinal
mass. Initially, it may look like a case of tuberculosis or lung cancer. Additional symptoms
may include chills, night sweats, fever, and weight loss.
Exam may show lymphadenopathy.
Chest X-ray and CT will show evidence of a mediastinal mass. Lymph node biopsy or
­mediastinoscopy is needed for definitive diagnosis.
Management
n
n
Surgery is generally preferred if localized. Consult general surgery, hematology/oncology and
radiation therapy.
Counseling regarding cancer diagnosis.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Chest X-ray, PA/lateral
•Sputum studies (for culture, AFB,
•Chest CT with contrast
fungus if sputum present)
•Lymph node biopsy (or
mediastinoscopy)
•Consult, thoracic surgery
•Reassure patient
•Consult, hematology/oncology
•Counsel patient
Consult, radiation therapy
•Advise patient, cancer diagnosis
•Not important for this case.
•In general, treat as outpatient, unless severe illness.
•Management should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Heart, Lungs, Lymph nodes ± Others
Chest X-ray, PA/lateral
Advance clock to results of chest X-ray.
Chest CT, Lymph node biopsy (or mediastinoscopy)
Reschedule patient to after results of biopsy.
Advise patient cancer diagnosis, Consult thoracic surgery,
Consult hematology/oncology, Consult radiation
oncology, Reassure patient, Counsel patient
Advance clock to additional results and case end.
None
149
10—COUGH
Case #62
Location: Office
Chief Complaint: Hoarseness in voice
Case introduction
Initial vital signs
Initial history
•A 70-year-old African American man arrives at the office for a 3-month history of cough and hoarseness of voice.
•Unremarkable
•The patient has experienced worsening hoarseness in his voice over the
past 3 months. He has had some difficulty swallowing over the past 4 weeks
associated with a sore throat. He has had a mild, intermittent cough for
the past several years. He has not experienced shortness of breath, fever,
constipation, or diarrhea. He has smoked two packs of cigarettes a day for
the past 45 years.
•Past medical history includes chronic bronchitis.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
150
II—CCS CASES BY CHIEF COMPLAINT
Case #62: Laryngeal Cancer
Keys to Diagnosis
n
n
n
Look for a patient with history of smoking who presents with cough, hoarseness, and change
in voice.
Exam is generally unremarkable.
Diagnosis is by laryngoscopy (laryngeal biopsy).
Management
n
n
Treatment with surgery (otolaryngology), radiation therapy, or chemotherapy, depending on
stage.
Counseling regarding cancer diagnosis. Stage with imaging of neck and chest.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Laryngeal biopsy, by direct laryngoscopy
THERAPY
•Advise patient, cancer diagnosis
•Consult, otolaryngology
•Consult, hematology/oncology
•Consult, radiation therapy
•CT, neck
•Chest CT with contrast
•Counsel patient
•Reassure patient
•Advise patient, advance
directive
•Advise patient, no smoking
•Advise patient, no alcohol
MONITORING
LOCATION
TIMING
•Not important for this case.
•Office, managed as an outpatient.
•Management should be instituted within 4 days of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Heart, Lungs, Lymph nodes, Extremities
Laryngeal biopsy, CT neck
Reschedule patient after results are reported.
Chest CT, Advise patient cancer diagnosis, Reassure patient,
Consult otolaryngology, Consult hematology/oncology,
Consult radiation therapy, Advise patient no smoking, Advise
patient no alcohol
Advance to additional results and patient updates.
Advise patient advance directive
151
10—COUGH
Case #63
Location: Emergency department
Chief Complaint: Cough and rhinorrhea
Case introduction
Initial vital signs
Initial history
•A 10-month-old white girl arrives at the emergency department with her
mother for a 2-day history of cough.
•Temperature: 38.1 degrees C (100.6 degrees F)
•The patient is typically healthy but developed fever and rhinorrhea beginning 3 days ago. The patient has also has had a loud, harsh cough for 2
days that is not associated with sputum. The symptoms appear to worsen
at night and when the child is fussy. The symptoms have caused difficulty
sleeping at night. Over the past day, the patient also has had difficulty swallowing. There are no other members of the household with symptoms.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Lethargic child with harsh cough and slight drool.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Mild use of accessory muscles for respiration. No
abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
152
II—CCS CASES BY CHIEF COMPLAINT
Case #63: Croup (Laryngotracheobronchitis)
Keys to Diagnosis
n
n
n
Look for child between the ages of 1 and 6 years presenting with rhinorrhea, a barking
cough, sore throat, or wheezing. Vital signs may show fever and tachycardia.
On exam, there may be stridor or use of accessory muscles.
Diagnosis is based on clinical history. X-ray of the soft tissue of the neck may show classic
“steeple” sign. Parainfluenza virus serology and other viral testing is generally not needed.
Management
n
n
For mild disease, provide supportive therapy because it is generally self-limited.
For severe symptoms, use oxygen, racemic epinephrine, and corticosteroids and change location to inpatient unit.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Skin, HEENT, Chest •RSV antigen, throat, by DFA
•Pulse oximetry
•Influenza throat swab
•Neck X-ray, soft tissue
•If severe symptoms:
•Counsel parents
•Oxygen
•Epinephrine, therapy
•Dexamethasone, oral
•Pulse oximetry
•Admit to inpatient unit if severe symptoms, such as difficulty swallowing,
respiratory distress, or pulse oximetry <92%.
•Management should be instituted within 2 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
End Orders
General, Skin, HEENT, Chest, Heart, Extremities
Pulse oximetry, Neck x-ray soft tissue
Advance clock to X-ray results.
If severe symptoms: Oxygen, Epinephrine, Dexamethasone,
RSV antigen, Influenza throat swab
Advance to additional results.
Vital signs
Inpatient unit (if meets criteria)
Advance to additional patient updates and case end.
None
10—COUGH
153
Cough—Key Points
n
any different types of cases can present with cough, including a variety of infections and
M
cancers. Orders to keep in mind to aid in the differential include:
n Peak flow
n Chest X-ray
n Chest CT scan
n Neck X-ray, soft tissue
n Bronchoscopy
n PPD
n Sputum stains and cultures
n HIV rapid antibody test and ELISA
C H A P T E R
11
Trauma
Key Orders*
Time to Results—
ED Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor,
continuous
Cardiac monitor
Needle thoracentesis
Thoracostomy, needle
Chest tube
Temporary pacemaker,
transthoracic
Chest X-ray, portable
ECG, 12-lead
ABG
Cervical spine films, portable
Echocardiography
CBC with differential
BMP
PT/PTT
Cervical spine CT scan
Pelvic X-ray, portable
FAST Ultrasound
Pulse oximetry
Monitor, continuous blood
pressure cuff
Monitor, cardiac
Thoracentesis
Needle thoracostomy
Tube thoracostomy
Pacemaker, temporary, transthoracic
1 min
5 min
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
X-ray, spine, cervical, portable
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
CT, spine, cervical
X-ray, pelvis, portable
US, focused assessment sonography
for trauma
Ethanol, serum
Pacemaker, temporary, transvenous
10 min
15 min
18 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
Troponin I, serum
Pericardiocentesis
Pacemaker, permanent
Amylase, serum
Toxicology screen, urine
Liver function panel
45 min
45 min
1 hr
1 hr
2 hr
2 hr
Blood alcohol
Temporary pacemaker,
transvenous
Troponin I, serum
Pericardiocentesis
Permanent pacemaker
Amylase
Urine toxicology screen
LFT
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
5 min
5 min
5 min
5 min
5 min
30 min
30 min
155
11—TRAUMA
Case #64
Location: Emergency Department
Chief Complaint: Chest pain, shortness of breath after an MVA
Case introduction
Initial vital signs
Initial history
•A 23-year-old white man is brought to the emergency department for chest
pain and shortness of breath after a motor vehicle accident.
•Pulse: 124 beats/min
•Respiratory rate: 31/min
•Blood pressure, systolic: 95 mm Hg
•Blood pressure, diastolic: 55 mm Hg
•The patient was an unrestrained driver in a motor vehicle accident. He was
not wearing a seatbelt, and his chest hit the steering wheel on impact.
There was no head injury or loss of consciousness. He was initially alert, but
became more dyspneic, agitated, and restless in the ambulance before arrival
to the emergency department.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Pulse oximetry, Blood pressure monitor, Cardiac monitor
Exam
•General, Chest, Heart, Abdomen
Initial Results: Time Course: 4 minutes to advance to results of physical exam
Pulse Oximetry
85% on room air
Results (Pertinent Findings)
General
Well developed; appears in acute distress; moaning.
Chest
Chest wall with bruising on the left; breath sounds present bilaterally.
Heart
Tachycardia; heart sounds very faint and soft; no murmurs. Bilateral central and
peripheral pulses weak. Jugular venous distention up to 14 cm.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not palpable.
Extremities
Extremities symmetric without deformity. Cyanosis in fingers and toes. No edema.
Bilateral peripheral pulses weak but equal. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
156
II—CCS CASES BY CHIEF COMPLAINT
Case #64: Cardiac Tamponade
Keys to Diagnosis
n
n
n
Look for a patient following a trauma/MVA with injury to the chest. The most common
symptoms for acute cardiac tamponade are dyspnea, dizziness, chest pain, drowsiness, and
palpitations. Vital signs show hypotension, tachycadia and tachypnea.
Exam shows diminished heart sounds, distended neck veins, weak pulses. Exam may also
show pulsus paradoxus (systolic blood pressure decreases >12 mm Hg during inspiration).
Diagnosis is based on Beck’s triad (hypotension, diminished heart sounds, distended neck
veins) and should be made on the examination. A FAST ultrasound can help confirm the
diagnosis. Other studies, such as chest X-ray (cardiomegaly), ECG (electrical alternans), and
echocardiography (pericardial fluid collection) should not delay treatment.
Management
n
n
n
Pericardiocentesis (automatic consult cardiothoracic surgery) should be ordered as quickly as
possible.
Supportive care—oxygen, IV fluids, monitor vital signs.
Treatment of trauma injuries—pain relief, X-rays, trauma studies, toxicology.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Lungs, Heart
•FAST Ultrasound
THERAPY
•Exam: Additional
•Chest X-ray, portable
•ECG, 12 lead
•Echocardiography
•Trauma studies (CBC, BMP, PT/PTT, Troponin)
•MVA studies (C-spine CT, Pelvic X-ray, Alcohol,
blood, Toxicology screen, Amylase, LFT)
•Intravenous access
•Morphine, intravenous, one-time/bolus
•Advise patient, drive with seat belt
•Pericardiocentesis
(consult, cardiothoracic
surgery)
•Oxygen
•Normal saline, 0.9% NaCl
•Blood pressure monitor,
•Vital signs
continuous
•Cardiac monitor
•Pulse oximetry
•Transfer to ICU for monitoring after pericardiocentesis.
•Management should be instituted within 1 hour of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Exam
Orders
Clock
Exam
Location
Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, Heart, Lungs, Abdomen, Extremities
Intravenous access, Normal saline 0.9% NaCl, Pericardiocentesis
(Consult, cardiothoracic surgery), Oxygen, Morphine
Additional exam
FAST ultrasound, Chest X-ray, ECG, Echocardiography, CBC, BMP,
PT/PTT, Troponin, Amylase, Alcohol blood, CT cervical spine,
Pelvic X-ray, Toxicology urine
Advance to results of pericardiocentesis.
Heart, lungs, extremities.
Transfer to ICU.
Chest X-ray, Echocardiography, Vital signs
Clock
Advance to additional results, patient feedback, and case end.
End Orders Advise patient drive with seat belt
157
11—TRAUMA
Case #65
Location: Emergency Department
Chief Complaint: Confusion after an MVA
Case introduction
Initial vital signs
Initial history
•A 63-year-old man is brought to the emergency department for confusion after a
motor vehicle accident.
•Pulse: 46 beats/min
•Respiratory rate: 29/min
•Blood pressure, systolic: 98 mm Hg
•Blood pressure, diastolic: 58 mm Hg
•The patient was the restrained driver in a motor vehicle accident with a parked car.
His chest hit the steering wheel on impact. He was found confused and dazed by
ambulance personnel. There was no head injury or loss of consciousness.
•All other history is unobtainable.
INITIAL MANAGEMENT
Orders
•Pulse oximetry, Blood pressure monitor, Cardiac monitor
Exam
•General, Chest, Heart
Initial Results: Time Course: 3 minutes to advance to results of physical exam
Pulse Oximetry
91% on room air
Results (Pertinent Findings)
General
Well developed; appears confused.
Chest
Chest wall with bruising on the sternum. Breath sounds present bilaterally.
Heart
Bradycardia; heart sounds normal. No murmurs. Bilateral central and peripheral pulses
weak. Mild jugular venous distention.
What is the suspected diagnosis, and what are the next steps in management?
158
II—CCS CASES BY CHIEF COMPLAINT
Case #65: Complete Heart Block (Third-Degree
Atrioventricular)
Keys to Diagnosis
n
n
n
Common symptoms include fatigue, dizziness, chest pain, dyspnea, confusion, and syncope.
Vital signs show bradycardia, hypotension and tachypnea.
On exam, look for signs of heart failure: jugular venous distension, rales, weak pulse,
­peripheral edema.
ECG is the diagnostic study of choice. Treatment should be initiated immediately after
ECG results.
Management
n
n
n
Temporary transthoracic pacemaker is the initial treatment of choice. It is preferred over
atropine, which may not work if the block is in the His bundle or if wide-complex bradyarrhythmia is present.
A permanent pacemaker should be ordered after the patient is stabilized. A transvenous
pacemaker is commonly ordered after transthoracic pacemaker in most real-world situations;
however, on the CCS, it is optional.
Supportive treatments—oxygen, IV fluids, pain relief. Treat any associated conditions.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Lungs, Heart
•ECG, 12-lead
THERAPY
•Chest X-ray, portable
•CBC
•BMP
•PT/PTT
•Troponin x3
•MVA studies if indicated (C-spine CT,
Pelvic X-ray, Blood alcohol,
Toxicology screen, Amylase, LFT)
•Intravenous access
•Morphine, intravenous, one-time/
bolus
•Pacemaker, temporary, transthoracic
•Pacemaker, permanent
•Normal saline, 0.9% NaCl
•Oxygen
•Blood pressure monitor, continuous
•Vital signs
•Pulse oximetry
•Cardiac monitor
•Admit to ICU for monitoring, especially if myocardial infarction or electrolyte
abnormalities present.
•Management should be instituted within 30 minutes of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Exam
Clock
Order
Clock
Location
Orders
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, Lungs, Heart
ECG 12-lead, Oxygen, Intravenous access, Normal saline
Additional
Advance to ECG.
Temporary transthoracic pacemaker, CBC, BMP, PT/PTT, Troponin,
MVA studies if indicated (Imaging, Toxicology, etc.)
Advance to pacemaker results.
Change to ICU.
Permanent pacemaker, Vital signs
Advance to additional results and case end.
None
159
11—TRAUMA
Trauma—Key Points
n
n
n
onitoring orders (pulse oximetry, blood pressure monitor, cardiac monitor) do not take
M
time off the clock and should be ordered before the physical exam based on abnormal vital
signs.
The diagnosis in trauma/MVA cases can often be determined from a limited physical exam;
therefore, often the treatment should be initiated before any imaging or lab studies.
Trauma cases should provide rapid (in minutes) patient feedback. These cases usually last
only a few minutes to a couple of hours of simulated time.
Tension Pneumothorax
(Case #1)
Cardiac Tamponade Third-Degree AV
(Case #64)
Block (Case #65)
Symptoms
Dyspnea, agitation, restlessness
Fatigue, dizziness,
chest pain, dyspnea,
confusion, syncope
Vital Signs
Tachycardia, hypotension,
tachypnea
Physical Exam
Chest exam with absent
breath sounds and
hyperresonance on affected
side; tracheal deviation
Lung exam ± chest X-ray or
FAST ultrasound
Needle thoracostomy for
immediate relief and to
confirm diagnosis
Tube thoracostomy to
prevent recurrence
Dyspnea, dizziness,
chest pain,
drowsiness and
palpitations
Tachycardia,
hypotension,
tachypnea
Heart exam with
soft or distant
heart sounds
Cardiac exam ±
FAST ultrasound
Pericardiocentesis
ECG, 12-lead
Diagnostic Test
of Choice
Treatment
n
n
Bradycardia,
hypotension,
tachypnea
Weak pulses
Temporary
transthoracic
pacemaker for initial
stabilization followed
by permanent
pacemaker
ncillary orders, such as pain relief and routine trauma orders, are appropriate but optional
A
during the time frame of these cases if appropriate primary management is quickly instituted. Most of these orders will likely not add significantly to your score.
In addition, transferring patients and counseling orders are generally optional in the time
frame of these cases.
C H A P T E R
12
Shortness of Breath
Key Orders*
Time to Results—
ED Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Peak flow
Chest X-ray, portable
ECG, 12-lead
ABG
Chest X-ray, PA/lateral
Flow spirometry
Echocardiography
CBC with differential
BMP
PT/PTT
Transesophageal echocardiogram
D-dimer, plasma
Spiral CT, chest with contrast
Troponin I, serum
BNP
Cardiac catheterization,
angiocardiography
PCI (Percutaneous coronary
intervention)
Duplex scan, leg, venous
RSV antigen, throat, by DFA
Pulse oximetry
Monitor, continuous blood pressure cuff
Monitor, cardiac
Peak flow
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
X-ray, chest, PA/lateral
Spirometry, flow
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
Echocardiography, transesophageal
D-dimer, plasma
CT, chest, with contrast
Troponin I, serum
B-type natriuretic peptide, serum
Angiocardiography, right and left heart
1 min
5 min
5 min
5 min
10 min
15 min
18 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
45 min
1 hr
1 hr
Angioplasty with stent placement,
coronary artery
Doppler, lower extremities, venous
Antigen, respiratory syncytial virus,
throat, DFA
Open heart surgery
Respiratory syncytial virus culture, throat
Serology, respiratory syncytial virus
1 hr
CABG
RSV culture, throat
RSV antibody, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
2 hr
2 hr
4 hr
3 days
6 days
12—SHORTNESS OF BREATH
161
Case #66
Location: Emergency Department
Chief Complaint: Shortness of breath, facial swelling
Case introduction
Initial vital signs
Initial history
•A 25-year-old white woman is brought to the emergency department for shortness of breath and facial swelling that began 45 minutes ago.
•Pulse: 120 beats/min
•Respiratory rate: 34/min
•Blood pressure, systolic: 104 mm Hg
•Blood pressure, diastolic: 62 mm Hg
•The patient was eating lunch at a restaurant with friends when her friends
noted she developed increasing redness in her face. Her face progressively
began to swell over the next 10 minutes, and she started developing shortness
of breath 5 minutes before arrival in the emergency department. Her meal at
the restaurant consisted of seafood salad that contained shellfish.
•Past medical history of eczema and asthma.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; short of breath.
HEENT/Neck
Normocephalic. Vision normal. Redness and swelling in the periorbital and
perioral region. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Tachypneic. Diaphragm and chest move equally and
symmetrically with respiration. Expiratory wheeze present.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses weak. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
162
II—CCS CASES BY CHIEF COMPLAINT
Case #66: Anaphylaxis
Keys to Diagnosis
n
n
n
Patients typically present with acute-onset shortness of breath, wheezing, facial swelling, and/or
skin redness. Look for a history of asthma or allergies and recent exposure to seafood (shellfish),
nuts, medication, or latex. Vital signs often show hypotension, tachycardia, or tachypnea.
On exam, look for swelling, redness, or angioedema on skin exam; wheezing on lung exam;
and weak pulse.
The diagnosis is clinical based on history and exam. The diagnosis should not be delayed for
additional studies such as ABG, chest X-ray, and ECG.
Management
n
n
n
ABCs—oxygen, IV fluids, intubation if needed. Monitor blood pressure, cardiac, and pulse
oximetry.
Epinephrine (SC or IM) and diphenhydramine (IV or IM) for initial treatment. Hydrocortisone IV to prevent recurrence. Albuterol may be used to control bronchospasms.
Counseling—advise to wear medic alert bracelet.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, Skin, HEENT, Lungs, Heart
•ECG, 12-lead
•Oxygen
•Intravenous access
•Epinephrine, therapy
•Normal saline, 0.9% NaCl
•Diphenhydramine hydrochloride
•Albuterol
•Hydrocortisone
•Counsel family/patient
•Advise patient, medic alert bracelet
•Reassure patient
•Blood pressure monitor, continuous
•Vital signs
•Pulse oximetry
•Cardiac monitor
•If mild episode, observe 2–6 hours in ED then discharge.
•If severe reaction (hypotension, upper airway involvement), observe in inpatient
unit for 24–48 hours.
•If refractory to initial treatment or continued hemodynamic instability, admit to
ICU.
•The diagnosis is based on clinical exam; therefore, initial management should
be started within 20 minutes.
Orders
Exam
Order
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, HEENT, Lungs, Heart
Intravenous access, Oxygen, Normal saline, Epinephrine,
Diphenhydramine, Albuterol
Clock
Advance clock to patient updates.
Order
Hydrocortisone, Vital signs, Reassure patient, Counsel family/patient,
Advise patient medic alert bracelet
Location
Inpatient unit
Clock
Advance to additional patient updates and case end.
End Orders None
12—SHORTNESS OF BREATH
163
Case #67
Location: Emergency Department
Chief Complaint: Shortness of breath, nausea
Case introduction
Initial vital signs
Initial history
•A 68-year-old woman is brought to the emergency department for shortness
of breath and nausea that began 1 hour ago.
•Pulse: 118 beats/min
•Respiratory rate: 31/min
•Blood pressure, systolic: 165 mm Hg
•Blood pressure, diastolic: 90 mm Hg
•The patient experienced sudden onset of shortness of breath, weakness,
and nausea beginning 1 hour ago. She was resting at home when the symptoms began. She has had occasional episodes of shortness of breath before
but not as severe as this. She does not have chest pain or cough.
•Past medical history includes diabetes, hypertension, and hyperlipidemia
treated with medications.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
97% on room air
Physical Exam Results (Pertinent Findings)
General
Overweight woman; short of breath.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Tachypneic. Diaphragm and chest move equally and
symmetrically with respiration. Pulmonary rales at the bases.
Heart/Cardiovascular
S1 and S2 normal. S3 heart sound present. No murmurs, rubs, gallops, or
extra sounds. Central and peripheral pulses normal. No jugular venous
distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
164
II—CCS CASES BY CHIEF COMPLAINT
Case #67: Myocardial Infarction
Keys to Diagnosis
n
n
n
Although the classic presentation is chest pain, watch for an atypical presentation—shortness
of breath, nausea, diaphoresis in a diabetic or elderly patient. Vitals may show hypertension,
tachycardia, or tachypnea.
On exam, look for abnormalities on lung, heart, and extremities exam—pulmonary rales,
jugular venous distention, murmurs, S3 or S4 heart sound, or peripheral edema.
ECG and troponin level confirms the diagnosis. Order labs and rule out other potential
causes, such as pulmonary embolism, CHF, COPD
Management
n
n
For myocardial infarction, immediate management (MONA): morphine (if pain present),
oxygen, nitroglycerin, aspirin. Also, most patients should receive a beta blocker and ACE inhibitor, unless contraindicated. Definitive therapy with coronary angiography and cardiology
consult or (stent placement)
If CHF also present, echocardiography, Urine output, Furosemide.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Heart, Lungs,
Extremities, Abdomen
•CBC
•ECG
•Chest X-ray, portable
•Troponin, every 6 hours ×3
•Echocardiography
THERAPY
•Exam: Complete
•ABG
•BMP
•PT/PTT
•Magnesium
•Urinalysis
•Lipid profile
•D-dimer
•BNP
•Morphine, IV (if severe pain)
•Clopidogrel, PO
•Intravenous access
•Furosemide (if CHF)
•Lisinopril, PO
•Bed rest
•Advise patient, no smoking
•Oxygen
•Aspirin, PO
•Nitroglycerin, SL
•Metoprolol, PO
•Heparin, IV
•Coronary angiography
•Consult, cardiology (or Coronary
artery stent placement)
•Cardiac monitor
•Urine output
•Blood pressure monitor
•Pulse oximetry
•Admit to inpatient unit or ICU depending on severity
•Management should be instituted within 1 hour of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, HEENT, Heart, Lungs, Extremities
ECG, CXR, CBC, BMP, D-dimer, Troponin every 6 hours x3,
BNP, PT/PTT, Magnesium, Phosphorus, IV access, Oxygen
Advance to ECG.
Aspirin, Nitroglycerin, Coronary angiography, Consult
cardiology
Advance to chest X-ray
If pulmonary edema present: Echocardiography, Urine output,
Furosemide
Advance to additional results and case end.
Advise patient no smoking
12—SHORTNESS OF BREATH
165
Case #68
Location: Emergency Department
Chief Complaint: Shortness of breath, cough, and wheezing
Case introduction
Initial vital signs
Initial history
•An 8-month-old male infant is brought to the emergency department by his
mother for shortness of breath, cough, and wheezing over the past 2 days.
•Temperature: 38.4 degrees C (101.2 degrees F)
•Respiratory rate: 54/min
•The patient has been experiencing an increased cough, wheeze, and shortness of breath over the past 2 days. The cough is associated with yellow
to white sputum, and the child has difficulty breathing when coughing. The
mother describes symptoms beginning with a runny nose, sneezing, and
fussiness about 5 days ago. The child is otherwise well and has not had previous infections.
•Past medical history is unremarkable. All vaccinations are up to date.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well-developed child, fussy in mother’s arms; occasional cough.
HEENT/Neck
Normocephalic. Eyes, including funduscopic examination, normal. Hearing
normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nasal mucosa red and edematous. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall with intercostal reactions and accessory muscle use. Diaphragm
and chest move equally and symmetrically with respiration. Wheeze
associated with cough.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
166
II—CCS CASES BY CHIEF COMPLAINT
Case #68: Bronchiolitis
Keys to Diagnosis
n
n
n
Look for a child younger than 1 year old who presents with cough, shortness of breath, difficulty feeding, and wheeze a few days after an upper respiratory tract infection. Vital signs
may show low-grade fever and tachypnea in severe disease.
Exam helps to assess severity. In severe disease, look for nasal flaring, intercostal retractions,
accessory muscle use, wheezing, and decreased breath sounds. Look for associated acute otitis
media.
Diagnosis is based primarily on history and exam. Order pulse oximetry to assess severity.
RSV antigen testing can help to confirm the diagnosis. A chest X-ray is generally not needed
unless severe disease is present.
Management
n
n
n
Supportive care with hydration and oxygen is the cornerstone of therapy.
Short-acting beta agonists or inhalational epinephrine is often used first line. Ribavirin is
used in severe disease. Antibiotics are not recommended unless the patient has concurrent
acute otitis media.
Inpatient admission if high risk: age <3 months, ill appearing, O2 saturation <95%, tachypnea
>70 breaths/min, or significant atelectasis on chest X-ray.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, HEENT, Chest
•Chest X-ray, PA/lateral
•Pulse oximetry
•RSV antigen, throat, by DFA
•Oxygen
•Consult, pediatrics
•Short-acting beta agonist (e.g.,
•Chest physiotherapy
albuterol) or epinephrine
•Normal saline, 0.9% NaCl
•Ribavirin (if severe disease)
•Pulse oximetry
•Admit to inpatient unit if high-risk features.
•Management should be instituted within 2 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Clock
End Orders
General, Skin, HEENT, Chest, Heart, Extremities ± Others
Pulse oximetry, RSV antigen
Advance to pulse oximetry results.
Oxygen
Advance to RSV results.
Albuterol, Consult pediatrics, Chest physiotherapy, Ribavirin
(if severe disease), Vital signs
Advance to patient update
Inpatient unit if meets criteria
Advance to additional patient updates and case end.
None
12—SHORTNESS OF BREATH
167
Case #69
Location: Office
Chief Complaint: Shortness of breath on exertion
Case introduction
Initial vital signs
Initial history
•A 34-year-old white woman is brought to the emergency department by her
husband for a 3-day history of worsening shortness of breath.
•Pulse: 118 beats/min
•Respiratory rate: 27/min
•Blood pressure, systolic: 110 mm Hg
•Blood pressure, diastolic: 70 mm Hg
•The patient has had increasing shortness of breath over the past 3 days primarily associated with exertion. The symptoms began about 1 month ago with mild
shortness of breath when walking or exercising. She now feels short of breath
with little activity and sometimes at rest and feels fatigued even with little activity.
She had an upper respiratory tract infection, which resolved 1 month ago. There
is no history of chest pain, cough, diarrhea, or constipation.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Overweight woman with mild shortness of breath.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Pulmonary rales at bases.
Heart/Cardiovascular
S1 and S2 normal. Holosystolic murmur present. Central and peripheral pulses
narrow. Increased jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. 2+ pitting
peripheral edema. Peripheral pulses with tachycardia. No joint deformity or
warmth; full range of motion. Spine examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
168
II—CCS CASES BY CHIEF COMPLAINT
Case #69: Dilated Cardiomyopathy
Keys to Diagnosis
n
n
n
Look for a young patient with relatively recent-onset shortness of breath after an upper
respiratory infection. Typically, the shortness of breath is exertional. Additional symptoms
include fatigue and peripheral edema.
Exam shows features of heart failure—jugular venous distention, narrow pulse pressure, pulmonary rales, hepatomegaly, peripheral edema, S3 or S4 heart sound, mitral regurgitation
murmur, or peripheral edema.
Chest X-ray shows enlarged heart and interstitial pulmonary edema. ECG is nonspecific but
may show hypertrophy or arrhythmias. Diagnosis is confirmed by echocardiography. Rule
out other causes of shortness of breath with troponin and D-dimer.
Management
n
n
n
Medications: diuretics (e.g., furosemide), ACE inhibitor (e.g., lisinopril), and beta blocker
(e.g., carvedilol). Consult cardiology because some patients may proceed to heart transplantation.
Low-sodium diet, no alcohol.
Counseling.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Heart, Lungs, Extremities
•Chest X-ray, PA/lateral
•ECG, 12-lead
•BNP
•Echocardiography
•Exam: Additional
•CBC
•BMP
•Troponin ×3
•Urinalysis
•D-dimer
•Oxygen
•Counsel patient/family
•Diuretic (e.g., furosemide)
•Reassure patient
•ACE inhibitor (e.g., lisinopril)
•Advise patient, exercise program
•Beta blocker (e.g., carvedilol)
•Advise patient, no alcohol
•Diet, low sodium
•Consult, cardiology
•Pulse oximetry
•Urine output
•Admit to inpatient unit for initial diagnosis and management, particularly if
heart failure is present.
•Management should be instituted within 2 hours of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Exam
Clock
End Orders
Pulse oximetry, Cardiac monitor, Blood pressure monitor
General, Heart, Lungs, HEENT, Abdomen, Extremities,
Neurologic
ECG 12-lead, Chest X-ray PA/lateral, CBC, BMP, BNP, Troponin,
Urinalysis, D-dimer, Oxygen
Advance to chest X-ray.
Echocardiography
Advance to additional results
Furosemide, Lisinopril, Carvedilol, Consult cardiology, Diet low
sodium, Urine output, Advise patient no alcohol, Reassure patient
Advance to additional results.
Change to inpatient unit
General, chest, heart, extremities
Advance to additional results, updates and case end.
Chest X-ray, Advise patient exercise program
169
12—SHORTNESS OF BREATH
Case #70
Location: Inpatient Unit
Chief Complaint: Shortness of breath during hospitalization
Case introduction
Initial vital signs
Initial history
•You are called to see a 64-year-old Latino man in the inpatient unit
for increasing shortness of breath over the past 30 minutes.
•Pulse: 121 beats/min
•Blood pressure, systolic: 155 mm Hg
•Blood pressure, diastolic: 91 mm Hg
•Respiratory rate: 31/min
•The patient was admitted to the hospital 3 days ago for communityacquired pneumonia and was improving until 30 minutes ago when he
started developing increasing shortness of breath. The shortness of
breath improves when sitting up and worsens when lying down. There
is no associated chest pain, abdominal pain, cough, or shaking chills.
•Past medical history of hypertension treated with hydrochlorothiazide and myocardial infarction treated with coronary artery stent 1
year ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
95% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed man sitting up in bed, short of breath.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and
symmetrically with respiration. Bilateral basilar rales present.
Heart/Cardiovascular
S1 and S2 normal. S3 heart sound present. No murmurs, rubs,
gallops, or extra sounds. Central and peripheral pulses normal.
Increased jugular venous distention present. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver
and spleen not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. 1+
pitting peripheral edema. Peripheral pulses with tachycardia. No joint
deformity or warmth; full range of motion. Spine examination results
normal.
What is the suspected diagnosis, and what are the next steps in management?
170
II—CCS CASES BY CHIEF COMPLAINT
Case #70: Congestive Heart Failure
Keys to Diagnosis
n
n
n
Look for patient with recent-onset shortness of breath. There is often a history of hypertension, coronary artery disease, or myocardial infarction.
Exam shows features of heart failure—jugular venous distention, narrow pulse pressure,
­pulmonary rales, hepatomegaly, peripheral edema, S3 or S4 heart sound, mitral regurgitation
murmur, or peripheral edema.
Diagnosis based on chest X-ray, BNP, and echocardiography. Rule out other causes, such as
myocardial infarction (troponin, ECG) and pulmonary embolism (D-dimer).
Management
n
n
n
edications: diuretics (e.g., furosemide), ACE inhibitor (e.g., lisinopril), and beta blocker
M
(e.g., metoprolol).
Monitor urine output and weight.
Counseling regarding diet and lifestyle modifications—low sodium, no alcohol.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Heart, Lungs, Extremities
•Chest X-ray, portable
•ECG
•BNP
•Echocardiography
THERAPY
•Exam: Additional
•CBC
•BMP
•Troponin x3
•Urinalysis
•D-dimer, plasma
•Reassure patient
•Diet, low sodium
•Advise patient, no alcohol
•Advise patient, exercise program
•Urine output
•Weight
•Oxygen
•Diuretics (e.g., furosemide)
•ACE inhibitor (e.g., lisinopril)
•Beta blocker (e.g., metoprolol)
•Pulse oximetry
•Blood pressure monitor
•Cardiac monitor
•Treat on inpatient unit.
•Management should be instituted within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Cardiac monitor, Blood pressure monitor, Pulse oximetry
General, Heart, Lungs, HEENT, Abdomen, Extremities
Oxygen, ECG 12-lead, Chest X-ray portable, CBC, BMP, BNP,
Troponin, Urinalysis, D-dimer
Advance to ECG, chest X-ray results.
Echocardiography
Advance to echocardiography results.
Medications (e.g., furosemide, lisinopril, metoprolol), Diet low
sodium, Urine output, Reassure patient
Advance to additional results, patient updates, and case end.
Chest X-ray, Advise patient exercise program, Advise patient
no alcohol
12—SHORTNESS OF BREATH
171
Case #71
Location: Emergency Department
Chief Complaint: Shortness of breath and fever
Case introduction
Initial vital signs
Initial history
•A 31-year-old Latina woman is brought to the emergency department for a
1-week history of worsening shortness of breath and chills.
•Temperature: 40.1 degrees C (104.2 degrees F)
•Pulse: 120 beats/min
•Respiratory rate: 34/min
•The patient has experienced worsening shortness of breath over the past 5 days.
She also has had several episodes of shaking chills and night sweats over the past
2 days. She has felt weak and fatigued despite little activity. She normally lives in a
homeless shelter and was referred to the emergency department by workers there.
•Past medical history for two previous visits for drug overdose.
•Social history includes a 2-year history of IV drug (heroin) use. She smokes onehalf pack of cigarettes a day and occasionally drinks alcohol.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
•Cardiac monitor, Pulse oximetry
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Thin woman; looks fatigued with mild shortness of breath.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. Systolic murmur present. Central and peripheral pulses
normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Fingers with clubbing and splinter hemorrhages. No edema. Peripheral
pulses normal. No joint deformity or warmth; full range of motion. Spine
examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
172
II—CCS CASES BY CHIEF COMPLAINT
Case #71: Infective Endocarditis
Keys to Diagnosis
n
n
n
Look for an adult patient with fever, chills, shortness of breath, weakness, sweats, cough, or
chest pain. Risk factors include IV drug use, prosthetic heart valve, and intravenous catheter.
Vital signs show fever.
Exam typically shows a murmur and may show Osler nodes, splinter hemorrhages, petechiae,
or splenomegaly
Take all cultures before starting antibiotics. Diagnosis is based on transesophageal echocardiogram. Rule out other causes.
Management
n
n
n
Empiric antibiotics: multiple options available. For example, for IV drug user (vancomycin
+ gentamicin) for prosthetic heart valve (vancomycin, rifampin, gentamicin). Alter medications based on susceptibility results if needed.
Admit to inpatient unit and treat until blood cultures results are negative.
For IV drug user—counseling, social services, evaluation for other diseases (hepatitis, HIV).
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Heart, Lungs, Extremities
•Chest X-ray, PA/lateral
•ECG
•Blood culture
•Transesophageal echocardiography
•Exam: Additional
•CBC
•BMP
•Troponin x3
•Urinalysis
•Urine culture
•D-dimer, plasma
•Empiric antibiotics (e.g., gentamicin +
•Counsel patient
vancomycin for IV drug use history)
•Reassure patient
•Consult, infectious disease
•Consult, social services
•Pulse oximetry
•Blood cultures daily until negative
•Transfer to inpatient unit until blood cultures are negative.
•Management should be instituted within 2 hours of simulated time.
Orders
Exam
Orders
Clock
Orders
Location
Clock
End Orders
Pulse oximetry, Cardiac monitor
General, Heart, Lungs, HEENT, Abdomen, Extremities, Neurologic
Oxygen, ECG 12-lead, Chest X-ray PA/lateral, CBC, BMP, Troponin,
Blood culture, Urinalysis, Urine culture, D-dimer, Transesophageal
echocardiography
Advance to echocardiography.
Antibiotics (e.g., gentamicin, vancomycin), Consult infectious
disease, Counsel patient, Reassure patient
Inpatient unit
Advance to additional results and case end.
Consult social services, Blood cultures daily
12—SHORTNESS OF BREATH
173
Case #72
Location: Inpatient unit
Chief Complaint: Shortness of breath after surgery
Case introduction •You are called to the inpatient unit to see a 61-year-old woman with acute-onset
shortness of breath that began 30 minutes ago.
Initial vital signs
•Pulse: 118 beats/min
•Respiratory rate: 29/min
Initial history
•The patient was admitted to the hospital 2 days ago for colon resection for colon
adenocarcinoma. The surgery and postoperative course were uneventful until the patient began having acute shortness of breath 30 minutes ago while lying in bed. The
patient also describes right-sided chest pain, which feels like a heavy pressure rated 6
on a 10-point scale. She has not experienced cough, hemoptysis, or abdominal pain.
•Past medical history includes colon cancer resected 2 days ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
Exam
•Blood pressure monitor, Cardiac monitor, Pulse oximetry
•General, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
95% on room air
Physical Exam Results (Pertinent Findings)
General
Overweight, female; short of breath, in moderate distress.
Chest/Lung
Chest wall normal. Tachypnea. Diaphragm and chest move equally and
symmetrically with respiration. Mild right-sided rales present.
Heart/Cardiovascular
Tachycardia. Loud S2. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Well healing surgical scar present. Bowel sounds normal; no bruits.
No masses or tenderness. Liver and spleen not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. Swelling and
tenderness of the left calf. Peripheral pulses normal. No joint deformity or
warmth; full range of motion. Spine examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
174
II—CCS CASES BY CHIEF COMPLAINT
Case #72: Pulmonary Embolism
Keys to Diagnosis
n
n
n
Look for a patient with history of surgery or immobilization with acute shortness of breath
and chest pain. Vitals show tachypnea and tachycardia.
Exam may show loud S2, S3 heart sound, murmur, rales, or friction rub. Look for calf
­tenderness or swelling as evidence of deep vein thrombosis.
For patients with a moderate to high probability of PE, order spiral CT with contrast.
Rule out other causes such as myocardial infarction and congestive heart failure. Also order
­Doppler ultrasound of legs to look for DVT.
Management
n
n
n
Oxygen.
Anticoagulation can include unfractionated heparin, low-molecular-weight heparin, or ­newer
agents such as fondaparinux. Also, thrombolytic agents (e.g., urokinase) if massive PE with
­hemodynamic instability and no contraindications. If contraindication to anticoagulation, use
IVC filter.
Coumadin for long-term anticoagulation.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Lung, Heart, Extremities
•D-dimer
•ECG
•Spiral CT chest with contrast
•PT/PTT
•Duplex scan, leg, venous
THERAPY
•Exam: Additional
•Chest X-ray, portable
•ABG
•Troponin ×3
•BNP
•CBC
•BMP
•Intravenous access
•Normal saline, 0.9% NaCl
•Oxygen
•Anticoagulation (heparin,
enoxaparin, or fondaparinux)
•Coumadin
•Pulse oximetry
•PT/PTT
•Cardiac monitor
•Management should be performed in the ICU.
•Initial management should be instituted within 2 hours of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Location
Orders
Clock
Orders
Clock
Exam
Clock
End Orders
Cardiac monitor, Pulse oximetry
General, Heart, Lungs, Extremities
Change to ICU
Oxygen, ECG 12-lead, ABG, Chest X-ray portable, Spiral CT chest
with contrast, D-dimer, Troponin x3, BNP, CBC, BMP, PT/PTT
Advance to CT results.
Anticoagulation (heparin, enoxaparin, or fondaparinux), Coumadin,
intravenous access, normal saline
Advance to patient update.
General, chest, heart
Advance to additional updates and case end.
PT/PTT, Counsel patient
12—SHORTNESS OF BREATH
175
Case #73
Location: Office
Chief Complaint: Shortness of breath on exertion
Case introduction
Initial vital signs
Initial history
•A 63-year-old man presents to the office for a 2-month history of shortness of
breath on exertion.
•Unremarkable
•The patient describes increasing shortness of breath when jogging or exercising. He previously was getting short of breath with heavy exercise but now
gets short of breath with walking or climbing stairs. During the past week, he
has also experienced shortness of breath while sleeping, which wakes him up
at night. He uses three pillows to sleep at night. He has not experienced chest
pain, abdominal pain, night sweats, cough, or diarrhea.
•Past medical history of hyperlipidemia and coronary artery disease treated with
medications.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. Loud systolic murmur best heard at the base. Central and
peripheral pulses narrow. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses narrow. No joint deformity or warmth; full range of motion.
Spine examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
176
II—CCS CASES BY CHIEF COMPLAINT
Case #73: Aortic Stenosis
Keys to Diagnosis
n
n
n
Look for an adult patient with gradual development of symptoms—exertional dyspnea, orthopnea, chest pain, dizziness, lightheadedness, fatigue, or syncope.
On exam, look for loud systolic ejection murmur at the base of the heart and narrow pulse
­pressure.
Chest X-ray may show dilated aorta or calcifications, and ECG shows left ventricular
­hypertrophy. Echocardiography confirms the diagnosis. Cardiac catheterization estimates
the severity of disease.
Management
n
n
For medical management: avoid strenuous activity; use a low-sodium diet and diuretics.
Surgery with valve replacement in symptomatic patients if, on cardiac catheterization, a pressure gradient >50 mm Hg or valve area <1 cm2 is present.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Heart, Lungs, Extremities
•Exam: Additional
•Chest X-ray, PA/lateral
•CBC
•ECG
•PT/PTT
•Echocardiography
•Lipid profile
•Cardiac catheterization, Angiocardiography •D-dimer
•Aortic valve replacement
•Type and crossmatch, blood
•Consult, surgery, thoracic
•Reassure patient
•Not important for this case
•Admit to inpatient unit if congestive heart failure present.
•Management should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Lungs, Heart, Abdomen, Extremities, Skin
Chest X-ray PA/lateral, ECG, Echocardiography, CBC, PT/PTT,
Lipid profile, D-dimer
Reschedule patient after results are reported.
Cardiac catheterization angiocardiography
Reschedule patient after results are reported.
Aortic valve replacement (if meets criteria), Consult thoracic surgery,
Type and crossmatch blood, Counsel patient, Reassure patient
Advance to additional results and case end.
None
12—SHORTNESS OF BREATH
177
Case #74
Location: Office
Chief Complaint: Shortness of breath and cough
Case introduction
Initial vital signs
Initial history
•A 61-year-old man arrives at the office for a 6-month history of shortness of
breath and coughing.
•Pulse: 120 beats/min
•Respiratory rate: 31/min
•The patient has experienced increasing shortness of breath and cough with
sputum over the past 6 months. He has had a chronic cough for the past
5 years, which is occasionally associated with scant white sputum. The
coughing and shortness of breath appear to be worse with activity. He has
not experienced chest pain, nausea, vomiting, diarrhea, or abdominal pain.
•Past medical history is unremarkable.
•Social history includes smoking two packs of cigarettes a day for the past
33 years. He does not drink alcohol or use illegal drugs.
•Family history and review of systems unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Overweight, male; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall expanded. Tachypneic. Diaphragm and chest show reduced
movement with respiration and overall decreased breath sounds.
Heart/Cardiovascular
Tachycardia. S1 and S2 normal. No murmurs, rubs, gallops, or extra
sounds. Central and peripheral pulses normal. No jugular venous
distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
178
II—CCS CASES BY CHIEF COMPLAINT
Case #74: Chronic Obstructive Pulmonary Disease
(COPD)
Keys to Diagnosis
n
n
n
Look for a patient with a long, progressive history of shortness of breath, productive cough,
and wheezing along with a significant tobacco history. Vital signs may show tachypnea and
tachycardia.
Exam shows decreased breath sounds, wheezing, and chest hyperinflation.
The diagnosis is based on history and exam. In stable patients, order peak flow and spirometry for extent of disease. Chest X-ray helps to exclude other causes.
Management
n
n
n
For stable patients: avoid tobacco, weight loss, oxygen if O2 saturation <90%, bronchodilators
(e.g., albuterol), and inhaled steroids (e.g., fluticasone) if moderate to severe symptoms.
For acute exacerbation of COPD: Admit to inpatient unit or ICU, aerosolized beta2 agonists
(e.g., metaproterenol) or anticholinergic agents (e.g., ipratropium bromide) plus systemic
steroids (e.g., prednisone). Also, positive-pressure ventilation and antibiotics (e.g., azithromycin) if suspected infection.
Pneumococcal and influenza vaccine.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam: General, Chest, Heart
•Peak flow
•Spirometry, flow
•Chest X-ray, PA/lateral
•Pulse oximetry
•Advise patient, no smoking
•Oxygen (if O2 sat <90%)
•Bronchodilator (e.g., albuterol)
•Inhaled steroids (e.g., fluticasone) if moderate
to severe symptoms
•ECG, 12-lead
•Sputum culture
•Advise patient, no alcohol
•Advise patient, exercise
program
•Weight loss diet
•Pneumococcal vaccine
•Influenza vaccine
•Monitor stable patients with peak flow.
•Admit to inpatient unit if acute exacerbation (decreased O2 sat, severe
distress).
•Management should be instituted within 4 days of simulated time for a stable
patient.
Exam
Orders
Clock
Orders
General, Skin, Chest, Heart, Extremities ± Others
Peak flow, Spirometry, Pulse oximetry, Chest X-ray
Advance clock to results of initial studies.
Medications (bronchodilator, Inhaled steroid if appropriate), Advise
patient no smoking, Advise patient no alcohol, Weight loss
diet, Advise patient exercise program, Pneumococcal vaccine,
Influenza vaccine
Clock
Advance to patient updates and case end.
End Orders None
12—SHORTNESS OF BREATH
179
Shortness of Breath—Key Points
n
hortness of breath can represent an underlying cardiac or respiratory abnormality. ImporS
tant orders to keep in mind for diagnosis include:
n Chest X-ray
n Troponin x3
n CBC
n ECG, 12-lead
n BNP
n Echocardiography
n RSV antigen
n D-dimer
n Chest CT with contrast
C H A P T E R
13
Back Pain
Key Orders*
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor, continuous
Cardiac monitor
Chest X-ray, portable
ECG, 12-lead
ABG
Echocardiography
CBC with differential
BMP
PT/PTT
Troponin I, serum
Urine Gram stain
Pulse oximetry
Monitor, continuous blood pressure
cuff
Monitor, cardiac
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
Troponin I, serum
Gram stain, urine, unspun
Urinalysis
Urinalysis
Prostate ultrasound
US, prostate
Abdominal ultrasound
Abdominal CT scan with contrast
Spine X-ray, lumbosacral
US, abdomen
CT, abdomen/pelvis, with contrast
X-ray, spine, lumbosacral
Spine CT, lumbar
CT, spine, lumbar
Bone scan
Prostate, fine-needle aspirate
Scan, bone
Aspirate, prostate, fine-needle
SPEP
UPEP
Urine culture
PSA, serum, total
PSA, serum, free
DEXA scan
Protein electrophoresis, serum
Protein electrophoresis, urine
Bacterial culture, urine
Antigen, prostate-specific, serum
PSA panel, total/free
Bone densitometry
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
ED Setting (Stat)
1 min
5 min
5 min
10 min
15 min
18 min
30 min
30 min
30 min
30 min
45 min
20 min (stat),
1 hr (routine)
30 min (stat),
6 hr (routine)
30 min (stat),
4 hr (routine)
30 min
30 min
30 min (stat),
1 hr (routine)
4 hr (stat),
24 hr (routine)
24 hr
15 min,
results 24 hr
24 hr
24 hr
24 hr
24 hr
2 days
24 hr
181
13—BACK PAIN
Case #75
Location: Office
Chief Complaint: Back pain and weight loss
Case introduction
Initial vital signs
Initial history
•A 72-year-old African American man arrives at the office for a 2-week history
of back pain.
•Unremarkable
•The patient describes pain in his lower back, which began as a dull ache
several weeks ago and then progressed to a sharp pain 2 weeks ago that
has occasionally been severe. When severe, he rates the pain as an 8 on a
10-point scale. The pain occurs when twisting, particularly when playing golf.
There is no history of trauma to the area, and he has never experienced this
type of pain in the past. He also describes a 10-lb weight loss over the past
month despite no change in appetite. He has not experienced abdominal
pain, chest pain, shortness of breath, dysuria, or diarrhea.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin man in no apparent distress.
Lymph nodes
Enlarged inguinal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. Prostate firm and irregular. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination with mild tenderness in the S1 region.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
182
II—CCS CASES BY CHIEF COMPLAINT
Case #75: Prostate Cancer
Keys to Diagnosis
n
n
n
Look for a patient who presents with back pain (from metastasis), urinary frequency, fatigue,
weight loss, or abdominal pain. Vital signs may show reduced BMI from weight loss.
On exam, rectal exam shows abnormal prostate, tenderness on spine exam, and enlarged
lymph nodes may be present.
Initial evaluation is based on imaging and PSA level. Diagnosis is confirmed with biopsy and
bone scan.
Management
n
n
n
Counseling regarding cancer diagnosis
Treatment for prostate cancer can include watchful waiting, surgery, or radiation therapy
depending on stage of disease. Consult oncology, urology, and radiation therapy.
Palliative care with advance directive counseling.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Spine, Rectal
•Spine X-ray, lumbosacral
•Prostate ultrasound
•PSA, serum, total
•Prostate, fine-needle aspirate
•Bone scan
THERAPY
•Exam: Additional
•CBC
•BMP
•PT/PTT
•Urinalysis
•Abdominal CT scan
•Chest CT scan
•Reassure patient
•Advise patient, side effects of
medication
•Advise patient, advance directive
•Acetaminophen with oxycodone
•Advise patient, cancer diagnosis
•Consult, hematology/oncology
•Consult, urology
•Consult, radiation therapy
•Not important in the time frame of this case.
•Office
•Management should be instituted within 4 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
General, Lymph nodes, Abdominal, Rectal ± Others
Spine X-ray lumbosacral, Prostate ultrasound, Urinalysis
Advance clock to X-ray result.
Prostate fine-needle aspirate, PSA total, Acetaminophen with
oxycodone, Advise patient side effects of medication
Clock
Advance clock to reschedule patient after all results are reported.
Orders
CBC, BMP, PT/PTT, Bone scan, Advise patient cancer diagnosis,
Abdominal CT scan, Chest CT scan, Reassure patient
Clock
Advance clock to reschedule patient after all results are reported.
Orders
Consult urology, Consult hematology/oncology, Consult radiation
therapy, Advise patient advance directive
Clock
Advance to additional results and case end.
End Orders None
183
13—BACK PAIN
Case #76
Location: Office
Chief Complaint: Back pain with difficulty walking
Case introduction
Initial vital signs
Initial history
•A 71-year-old white woman is brought to the office by her daughter for a 2-day
history of back pain.
•Unremarkable
•The patient describes worsening back pain over the past 2 days. The pain began
as sudden, severe lower back pain that is only partially relieved with acetaminophen. The pain worsens when standing or walking and is partially relieved by lying
down. The pain causes difficulty bending, twisting, and walking. At its worst, the
pain is rated 7 on a 10-point scale. There is no history of trauma to the area.
•Past medical history of hyperlipidemia treated with a Atorvastatin. Menopause at
age 52 years.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, elderly woman with difficulty walking into room.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination shows kyphosis and tenderness on palpation of L4 region.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
184
II—CCS CASES BY CHIEF COMPLAINT
Case #76: Osteoporosis/Vertebral Fracture
Keys to Diagnosis
n
n
n
Look for an elderly female patient with a history of back pain. Risk factors include age,
­gender, family history, poor nutrition, physical inactivity, smoking, and estrogen deficiency.
Examination may show kyphosis and tenderness.
Diagnosis of fracture is based on X-ray. Osteoporosis diagnosis is made by DEXA scan. Rule
out other causes of fracture.
Management
n
n
n
Conservative management is first line therapy. Treat fracture with back brace and pain relief.
Treat osteoporosis with calcium and vitamin D supplementation plus osteoporosis medication (e.g., alendronate).
Counseling, advice exercise program after recovery.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Extremities, Neuro
•Spine X-ray, lumbosacral
•DEXA scan
THERAPY
•CBC
•BMP
•Phosphorus
•LFT
•TSH
•SPEP
•Diet, high calcium
•Physical therapy
•Advise patient, side effects of medication
•Advise patient, rest at home
•Reassure patient
•Back brace
•Acetaminophen with
oxycodone
•Calcium carbonate
•Vitamin D, therapy
•Alendronate
•Not important in the time frame of this case.
•Most patients can be managed as outpatients. Admit to inpatient unit if severe
pain requiring IV narcotics or requires vertebroplasty.
•Management should be instituted within 2 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
HEENT, Lymph Nodes, Extremities, Neuro ± Others
Spine X-ray, lumbosacral
Advance clock to spine X-ray.
CBC, BMP, Phosphorus, LFT, TSH, DEXA scan, Back brace,
Advise patient rest at home, Acetaminophen plus oxycodone
Clock
Advance clock to reschedule patient when all results are reported.
Orders
Calcium carbonate, Vitamin D, Alendronate, Diet high calcium,
Advise patient side effects of medication, Reassure patient
Clock
Advance to additional patient updates and case end.
End Orders Advise patient exercise program, Physical therapy
185
13—BACK PAIN
Case #77
Location: Emergency Department
Chief Complaint: Back and abdominal pain
Case introduction
Initial vital signs
Initial history
•A 68-year-old man is brought to the emergency department by ambulance for
severe back and abdominal pain that began 30 minutes ago.
•Pulse: 109 beats/min
•Respiratory rate: 25/min
•Blood pressure, systolic: 98 mm Hg
•Blood pressure, diastolic: 55 mm Hg
•The patient was brought to the emergency department by ambulance after
complaining of severe back pain at work. The pain is sharp, severe, and rated
9 on a 10-point scale. The pain radiates to the abdomen and groin. He has
never had this type of pain before. There is no history of infection, dysuria,
constipation, or diarrhea.
•Past medical history of hyperlipidemia and coronary artery disease treated
with medications.
•Social history includes smoking one pack of cigarettes a day for the past 45
years.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Overweight, male; holding his abdomen, moaning in distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Peripheral pulses
weak. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Pulsatile abdominal mass with bruit present. Liver and spleen not palpable.
No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses weak. No joint deformity or warmth; full range of motion.
Spine examination findings normal.
What is the suspected diagnosis, and what are the next steps in management?
186
II—CCS CASES BY CHIEF COMPLAINT
Case #77: Abdominal Aortic Aneurysm, Ruptured
Keys to Diagnosis
n
n
n
Look for a patient who presents with severe abdominal or back pain that radiates to the groin
or flank. Common risk factors include atherosclerosis and smoking. Signs of shock may also
be present, with vital signs showing hypotension.
Exam shows pulsatile abdominal mass and may show abdominal bruit or abdominal
distention.
Abdominal CT scan or ultrasound will identify the location and estimate the size of the
aneurysm. Abdominal X-ray is insensitive and should not delay the diagnosis.
Management
n
n
n
For ruptured AAA, laparotomy as quickly as possible. If the case is classic and the patient is
unstable, consider proceeding to laparotomy before imaging results.
Type and crossmatch blood; treat hypotension with blood pressure monitoring and fluids.
Counseling orders can be placed at case end for future time.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Abdomen, Heart, Lungs
•Abdominal CT scan with contrast
•CBC
THERAPY
•Oxygen
•Normal saline, 0.9% NaCl
•Laparotomy
•Consult, vascular surgery
•Type and crossmatch, blood
•Blood pressure monitor
•BMP
•Troponin
•ECG, 12-lead
•PT/PTT
•Intravenous access
•Morphine
•Advise patient, no smoking
MONITORING
LOCATION
TIMING
SEQUENCING
•Cardiac monitor
•Pulse oximetry
•Patient managed in the emergency department and taken to surgery.
•Management should be instituted within 1 hour of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
End Orders
Pulse oximetry, Blood pressure monitor, Cardiac monitor
General, Heart, Lungs, Abdomen, Extremities
Abdominal CT scan, Morphine, Oxygen, Intravenous
access, Normal saline, 0.9% NaCl,
Advance to CT scan.
Laparotomy, Consult vascular surgery, Type and
crossmatch blood, CBC, BMP, PT/PTT, ECG, Troponin
Advance to laparotomy and case end.
Advise patient, no smoking
187
13—BACK PAIN
Case #78
Location: Office
Chief Complaint: Back pain, painful urination
Case introduction
Initial vital signs
Initial history
•A 28-year-old man arrives at the office for a 3-hour history of worsening back
pain and painful urination.
•Temperature: 38.5 degrees C (101.3 degrees F)
•The patient describes lower back pain that began yesterday and has worsened
over the past 3 hours. The pain is predominantly in the lower back and radiates
to the groin. Nothing relieves the pain, which is rated a 7 on a 10-point scale.
He had two episodes of painful urination before arriving. He felt one episode
of shaking chills last night and woke up twice at night to urinate. There is no
history of penile discharge. He is sexually active with his girlfriend only and uses
condoms for contraception.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
Lymph nodes
No abnormal lymph nodes.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Rectal
Sphincter tone normal. Prostate tender on palpation. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination findings normal.
What is the suspected diagnosis, and what are the next steps in management?
188
II—CCS CASES BY CHIEF COMPLAINT
Case #78: Prostatitis, Acute Bacterial
Keys to Diagnosis
n
n
n
Look for an adult male patient with sudden-onset perineal or back pain, dysuria, urinary
frequency, nocturia, and chills. Vital signs may show fever.
On examination, the prostate is generally tender.
The diagnosis of acute bacterial prostatitis is clinical based on history and exam. Urinalysis
and culture may help isolate the organism. Do not order prostate massage in acute bacterial
prostatitis because it can force bacteria into the bloodstream.
Management
n
n
n
Empiric antibiotic therapy. Multiple options exist, such as a fluoroquinolone (e.g., ofloxacin)
for 30 days.
Pain relief with NSAIDs.
If severe symptoms, such as sepsis, admit to inpatient unit or ICU, order pelvis CT looking
for abscess and blood culture. If abscess present, order aspirate abscess or surgical consult and
IV antibiotics (e.g., gentamicin, ampicillin, and clindamycin).
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Rectal
•Urinalysis
•Urine Gram stain
•Urine culture
•Exam: General, Lungs, Heart, Genitalia
•If sepsis:
•CBC
•Blood culture
•Pelvis CT
•Antibiotic (e.g., ofloxacin) •Reassure patient
•Acetaminophen
•Counsel patient
•None, unless patient septic and hypotensive
•Most cases can be treated as an outpatient.
•If signs of sepsis with hypotension, admit to inpatient unit or ICU.
•Diagnosis and management should be instituted within 2 hours.
Exam
Order
Clock
Orders
Clock
End Orders
General, Abdomen, Genitalia, Rectal ± Complete
Urinalysis, Urine Gram stain, Urine culture
Advance clock to results of urinalysis and Gram stain.
Ofloxacin, Acetaminophen, Reassure patient, Counsel Patient
Advance clock to additional results, patient updates and case end.
None
189
13—BACK PAIN
Case #79
Location: Office
Chief Complaint: Back pain
Case introduction
Initial vital signs
Initial history
•A 62-year-old man arrives at the office for a 6-month history of back pain.
•Unremarkable
•The patient describes intermittent pain in his middle and lower back over
the past 6 months. The pain is described as deep, achy pain rated a 5 on a
10-point scale. The pain is worse at the end of the day and with sitting for long
periods of time. The pain is associated with difficulty twisting and bending.
Acetaminophen is used to provide relief of pain but only provides mild relief
over the past month. There is no history of trauma.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, overweight; mild difficulty walking into room.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination with mild tenderness on palpation of mid back. Difficulty
bending forward.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
190
II—CCS CASES BY CHIEF COMPLAINT
Case #79: Osteoarthritis
Keys to Diagnosis
n
n
n
ook for an adult patient with slowly progressive, deep, achy joint pain over months or
L
years. The pain is usually worse at the end of the day and with activity. Additional symptoms
include stiffness, tenderness, swelling, and decreased range of motion.
Exam shows decreased range of motion of affected joints and may show Heberden nodes or
osteophytes.
Diagnosis is based on X-ray of affected joint. Rule out other causes.
Management
n
n
n
ounseling with exercise, physical therapy, and braces.
C
Symptomatic treatment of pain. Begin with acetaminophen; then proceed to NSAIDs (e.g.,
naproxen) or a COX-2 inhibitor if risk of GI bleed (e.g., celecoxib). For severe pain, consider opioid analgesic (e.g., oxycodone). If medical management fails, consult orthopedic
surgery.
Weight loss if overweight.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Extremities
•X-ray of affected joints
THERAPY
•Exam: Additional
•Rheumatoid factor
•SPEP
•Reassure patient
•Physical therapy
•Weight-loss diet
•Pain relief (e.g., naproxen or
steroid)
•Back brace
•Advise patient, exercise program
•Not important in the time frame of this case.
•Office, managed as an outpatient.
•Management should be instituted within 2 days of simulated time with
follow-up over several weeks.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Extremities ± Others
Spine X-ray, lumbosacral
Advance clock to X-ray result.
Back brace, Pain relief (NSAID or opioid), Physical therapy,
weight loss diet, Rheumatoid factor, SPEP, Advise patient
exercise program, Reassure patient
Advance clock to additional updates and case end.
None
13—BACK PAIN
191
Back Pain—Key Points
n
n
n
I n male patients who present with back pain, be on the lookout for prostate abnormalities
(prostate cancer, prostatitis).
In female patients who present with back pain, watch for fracture related to osteoporosis or
arthritis.
In the office setting, orders to keep in mind that can help evaluate the cause of back pain
include:
n Spine X-ray, lumbosacral
n Urinalysis
n Urine Gram stain
n Prostate ultrasound
n Prostate, fine-needle aspirate (prostate biopsy)
n SPEP
n DEXA scan
C H A P T E R
14
Diarrhea
Key Orders*
Order
CCS Terminology
Pregnancy test, urine, qualitative
hCG, beta, urine, qualitative
HIV antibody test, rapid, blood
BMP
Antibody, rapid HIV test, blood
Basic metabolic profile
CBC
CBC with differential
Colonoscopy
Colonoscopy
EGD
Endoscopy, upper gastrointestinal
Barium enema
Barium enema
LFT
ESR
Sweat test
HIV test, ELISA, serum
Ferritin, serum
Iron, serum w/TIBC
Liver function panel
Sedimentation rate, erythrocyte
Chloride, sweat
Antibody, HIV, ELISA, serum
Ferritin, serum
Iron and total iron binding capacity,
serum
Vitamin B12, serum
Folic acid, serum
Bacterial culture, stool
Ova and parasites, stool
Antibody, antineutrophil cytoplasmic,
serum
Giardia antigen, stool
Clostridium difficile toxin assay, stool
B12, serum
Folate, serum
Stool C & S
Stool ova and parasites
P-ANCA
Stool Giardia antigen
Stool Clostridium difficile toxin
assay
Cystic fibrosis DNA detection,
blood
Stool fat, 72-hour
Time to Results—
Office Setting
5 min (stat) ,
20 min (routine)
20 min
30 min (stat),
2.5 hr (routine)
1 hr (stat),
24 hr (routine)
1 hr (stat),
24 hr (routine)
2 hr (stat),
24 hr (routine)
2 hr (stat),
24 hr (routine)
2.5 hr
4 hr
8 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
24 hr
2 days
2 days
3 days
Cystic fibrosis DNA detection, blood
4 days
Fat, 72-hour stool
4 days
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
193
14—DIARRHEA
Case #80
Location: Office
Chief Complaint: Diarrhea and abdominal pain
Case introduction
Initial vital signs
Initial history
•A 32-year-old white woman arrives at the office for a 2-month history of
intermittent watery diarrhea.
•Unremarkable
•The patient describes intermittent episodes of diarrhea over the past 2
months associated with four to five loose bowel movements per day. Her
stools are watery, and she has not noticed any blood or dark stools. The
episodes of diarrhea are generally associated with right lower quadrant
abdominal pain. The abdominal pain is sharp and rated a 6 on a 10-point
scale. She has also experienced fatigue and weakness. She has no change
in diet but has had reduced appetite and a 10-lb weight loss over the past
2 months. She has not had any recent travel. She is sexually active with her
husband only and has normal menstrual cycles.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and peripheral
Cardiovascular
pulses normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses; mild right lower quadrant abdominal
tenderness. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
194
II—CCS CASES BY CHIEF COMPLAINT
Case #80: Crohn’s Disease
Keys to Diagnosis
n
n
n
Look for a patient who presents with a several-month history of watery, nonbloody diarrhea. Other symptoms include tiredness, lethargy, anorexia, weight loss, abdominal pain, and
weakness.
Examination may show some abdominal tenderness but is generally unremarkable.
Diagnosis is based on colonoscopy and biopsy findings. Barium enema is considered outdated, and abdominal CT is used to identify complications, such as abscess formation. Look
for vitamin B12–associated macrocytic anemia and metabolic abnormalities. Rule out other
gynecologic pathology as indicated. P-ANCA to help rule out ulcerative colitis
Management
n
n
n
Medications: mesalamine or sulfasalazine with folate supplementation and prednisone for
acute exacerbations. Metronidazole for mild to moderate disease and azathioprine or surgery
for severe disease.
Diet (high fiber and low fat for diarrhea or elemental diet if severe symptoms).
Counseling and consult gastroenterology.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•CBC
•ESR
•Vitamin B12, serum
•Colonoscopy
•hCG, urine (if abdominal pain)
•Folic acid, serum
THERAPY
•BMP
•Stool C & S
•Stool ova and parasite
•Stool Clostridium difficile toxin
assay
•LFT
•P-ANCA
•Advise patient, side effects of
medication
•Counsel patient
•Reassure patient
•Consult gastroenterology
•Medications (mesalamine or sulfasalazine
or prednisone)
•Vitamin B12, therapy (if deficient)
•Folic acid, therapy
•Diet, low fat
•Diet, high fiber
•None
•Office; treated as an outpatient for mild to moderate disease.
•Therapy should be instituted within 4 days.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, HEENT, Abdomen, Rectal, Extremities ± Complete
CBC, BMP, ESR, hCG urine (if female), Stool C & S, Stool ova and
parasite, Stool Clostridium difficile toxin assay, Colonoscopy
Advance clock to results of CBC.
LFT, Vitamin B12 serum, Folic acid serum
Advance clock to reschedule patient when all results are reported.
Medications (Sulfasalazine, Prednisone or others depending on
severity), Vitamin B12 therapy, Folic acid therapy, Diet (low fat
and high fiber or elemental if severe), Advise patient side effects
of medication, Counsel patient, Reassure patient, Consult
gastroenterology
Advance to additional results, patient updates and case end.
None
195
14—DIARRHEA
Case #81
Location: Office
Chief Complaint: Diarrhea and constipation
Case introduction
Initial vital signs
Initial history
•A 46-year-old white woman arrives at the office for an 8-month history of diarrhea and constipation.
•Unremarkable
•The patient has been having intermittent episodes of diarrhea and constipation over the past several months. She describes episodes of diarrhea as
having three to four loose watery bowel movements a day that resolve after a
few days. She often has abdominal pain before bowel movements, which are
relieved with defecation. She has not noticed any blood in her stools. She also
has episodes of constipation where she does not have a bowel movement for
3 to 4 days. Her irregular bowel movements cause her increasing anxiety. She
has not had any recent travel. She is sexually active with her husband only.
•Past medical history of two childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
196
II—CCS CASES BY CHIEF COMPLAINT
Case #81: Irritable Bowel Syndrome
Keys to Diagnosis
n
n
n
Look for an adult patient, more often a woman, with a several-month history of multiple
complaints—watery diarrhea, abdominal pain, abdominal distention, abnormal defecation
(straining or incomplete evacuation), and changes in stool consistency or frequency. Often,
there is a history of psychiatric problems.
Examination is generally unremarkable.
Testing should rule out other diagnoses and can include CBC, stool for ova and parasites,
stool for C. difficile toxin, and/or colonoscopy.
Management
n
n
n
High-fiber diet is the mainstay of treatment.
Consider medications as adjuvant therapy, such as an anticholinergic (e.g., dicyclomine),
antidiarrheal (e.g., loperamide), or antidepressant (e.g., SSRI, amitriptyline).
Counseling and reassurance. Biofeedback may help with constipation.
DIAGNOSIS
THERAPY
OPTIMAL ORDERS
ADDITIONAL ORDERS
•CBC
•ESR
•Stool C & S
•Stool ova and parasites
•Stool for Clostridium difficile
toxin assay
•Dicyclomine hydrochloride
•Diet, high fiber
•Reassure patient
•Biofeedback
•BMP
•LFT
•TSH
•Colonoscopy
•Amitriptyline
•Loperamide
•Advise patient, limit caffeine intake
•Advise patient, limit alcohol intake
•Advise patient, exercise program
•Advise patient, side effects of medication
MONITORING
LOCATION
TIMING
•None
•Office; treated as outpatient.
•Diagnosis and treatment should be instituted within 4 days.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Abdomen, Rectal ± Additional
CBC, ESR, BMP, LFT, TSH, Stool C & S, Stool ova and parasites,
Stool for C. difficile toxin assay, Colonoscopy
Advance clock to reschedule patient when all results are reported.
Dicyclomine hydrochloride, Biofeedback, Diet high fiber, Advise
patient side effects of medication, Advise patient limit caffeine
intake, Advise patient limit alcohol intake, Advise patient
exercise program, Reassure patient
Advance to additional results, patient updates and case end.
None
197
14—DIARRHEA
Case #82
Location: Office
Chief Complaint: Diarrhea and failure to gain weight
Case introduction
Initial vital signs
Initial history
•A 7-month-old white male infant arrives at the office with his mother for a
3-week history of greasy diarrhea and failure to gain weight.
•Unremarkable
•The patient has been having greasy, foul-smelling stools for the past 3 weeks
associated with passing large amounts of gas. There is no blood associated with the stools. The mother describes difficulty feeding for the past 1 to
2 months, and the patient is often fussy and irritable after meals. He has not
gained any weight in the past several weeks. He has an older brother and sister
who have not had any symptoms nor has anyone else in the household. There
has been no recent travel.
•Past medical history of meconium ileus at birth.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, active infant; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall increased in diameter. Diaphragm and chest move equally
and symmetrically with respiration. No abnormality on percussion or
auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Hyperactive bowel sounds; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination findings normal.
What is the suspected diagnosis, and what are the next steps in management?
198
II—CCS CASES BY CHIEF COMPLAINT
Case #82: Cystic Fibrosis
Keys to Diagnosis
n
n
n
Look for an infant younger than 1 year old with foul-smelling, greasy diarrhea; failure to gain
weight; increased flatus; and irritability after meals. There may be a past history of pneumonia or meconium ileus.
Examination may show increased chest diameter, lung hyperresonance, or abdominal distention.
Diagnosis can be made by the sweat test for chloride and DNA testing. Other abnormalities
can include increased 72-hour fecal fat, low albumin, and abnormal chest X-ray findings.
Management
n
n
n
Pancreatic enzyme replacement and vitamin supplementation.
Referral to cystic fibrosis care center, dietary, genetics, and endocrinology.
Counseling.
OPTIMAL ORDERS
ADDITIONAL ORDERS
THERAPY
•Sweat test
•Cystic fibrosis DNA detection, blood
•Cystic fibrosis care center referral
•Pancreatic enzymes
•Multiple vitamins regular
•Chest X-ray, PA/lateral
•Stool 72-hour fat
•Counsel parent
•Consult, dietary
•Consult, genetics
•Consult, pediatric
endocrinology
MONITORING
LOCATION
TIMING
•None
•Office
•Management should be instituted within 1 day of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
DIAGNOSIS
Clock
End Orders
Complete
Sweat test, CF DNA detection blood, Stool 72-hour fat
Advance clock to reschedule patient after tests are reported.
Pancreatic enzymes, Cystic fibrosis care referral center,
Multiple vitamins regular, Counsel parent, Consult dietary,
Consult genetics, Consult pediatric endocrinology
Advance clock to additional results, patient updates and case
end.
None
199
14—DIARRHEA
Case #83
Location: Office
Chief Complaint: Bloody diarrhea
Case introduction
Initial vital signs
Initial history
•A 33-year-old white woman arrives at the office for a 1-week history of
bloody diarrhea.
•Unremarkable
•The patient began having three to four episodes of diarrhea daily beginning about 1 week ago. The symptoms started 1 month ago but were
intermittent. The stools are loose and have blood present. She also has
nausea and abdominal cramps. The diarrhea causes her to wake up at
night to defecate, and the symptoms have caused her to miss work. She
has not taken any medications for the symptoms. She has no recent
change in diet and has had a 10-lb weight loss over the past month. She
is sexually active only with her husband of 10 years. She uses condoms
for birth control.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, thin; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool dark brown with red
streaks. Occult blood present.
What is the suspected diagnosis, and what are the next steps in management?
200
II—CCS CASES BY CHIEF COMPLAINT
Case #83: Ulcerative Colitis
Keys to Diagnosis
n
n
n
Look for a patient who presents with a history of bloody diarrhea with nausea, anorexia,
weight loss, abdominal pain, or dehydration. Vital signs may show fever.
Examination may show blood in stool.
Diagnosis is established by colonoscopy and biopsy with P-ANCA supporting. Also check
for anemia and rule out other causes of diarrhea.
Management
n
n
n
For mild to moderate disease, use mesalamine.
For severe disease, use steroids (e.g., prednisone).
Treat anemia; correct nutritional deficiencies.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Complete
•BMP
•CBC
•ESR
•Colonoscopy
•LFT
•P-ANCA
•hCG, beta, urine, qualitative
•Mesalamine
•Consult, gastroenterology
•Iron sulfate (if iron deficiency)
•Consult, surgery, general
•Vitamin B12 (if B12 deficiency)
•None
•Mild disease can be managed as an outpatient. For severe disease, admit to
inpatient unit for bowel rest, parenteral nutrition, and colonoscopy.
•Therapy should be instituted within 3 days of simulated time.
Exam
Orders
Complete
CBC, BMP, LFT, HCG, ESR, P-ANCA, Stool ova and parasites,
Stool C. difficile toxin assay, Colonoscopy
Clock
Advance clock to results of CBC.
Orders
Vitamin B12, Ferritin, Iron and TIBC
Clock
Advance clock to reschedule patient after results are reported.
Orders
Mesalamine, Vitamin B12 therapy, Iron sulfate, Consult
gastroenterology, Consult surgery general
Clock
Advance to additional results, patient updates and case end.
End Orders None
201
14—DIARRHEA
Case #84
Location: Office
Chief Complaint: Watery diarrhea
Case introduction
Initial vital signs
Initial history
•A 28-year-old Latino man arrives at the office for a 2-week history of diarrhea.
•Unremarkable
•The patient began having four to five episode of diarrhea beginning about
2 weeks ago. The stools are watery and loose without blood present. He also
has increased flatulence and abdominal cramps. The diarrhea causes him to
wake up at night to defecate. He took over-the-counter diarrhea medications,
which did not relieve his symptoms. He has no recent change in diet. He goes
camping frequently for long periods but has not traveled outside the United
States. He is heterosexual and sexually active with one partner for the past
5 years. He uses condoms for birth control.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, thin; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Hyperactive bowel sounds; no bruits. No masses or tenderness. Liver and
spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Watery, loose brown stool;
no occult blood.
What is the suspected diagnosis, and what are the next steps in management?
202
II—CCS CASES BY CHIEF COMPLAINT
Case #84: Giardiasis
Keys to Diagnosis
n
n
n
Look for a patient with chronic watery diarrhea associated with cramping, bloating, and nausea. There is usually a history of travel to the woods, camping, or drinking from a fresh-water
source.
Exam may show hyperactive bowel sounds or watery stools on rectal exam.
Diagnosis is made by clinical features, stool Giardia antigen, and stool ova and parasite exam.
Management
n
n
n
Metronidazole for 7 days is the treatment of choice.
Avoid milk products owing to transient lactase deficiency.
Counseling and reassurance.
DIAGNOSIS
THERAPY
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam: Abdomen, Rectal
•Giardia antigen
•Stool ova and parasites
•Metronidazole
•Advise patient, avoid milk
•BMP
•Stool C & S
•Stool Clostridium difficile toxin assay
•Advise patient, side effects of medication
•Counsel patient
•Reassure patient
MONITORING
LOCATION
TIMING
•None
•Office, treated as outpatient.
•Management should be instituted within 2 days of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
General, Abdomen, Rectal ± Others
Stool Giardia antigen, Stool C & S, Stool ova and parasite, Stool
C. difficile toxin assay, BMP
Advance clock to reschedule patient after results are reported.
Metronidazole, Advise patient side effects of medication, Advise
patient avoid milk, Counsel patient, Reassure patient
Advance to additional patient updates and case end.
Cancel metronidazole after 7 days.
14—DIARRHEA
Diarrhea—Key Points
n
Important orders to keep in mind if you get a case of a patient with diarrhea:
n Colonoscopy
n CT, abdomen
n P-ANCA
n Stool C & S
n Stool Clostridium difficile toxin assay
n Stool ova and parasites
n Stool Giardia antigen
n Sweat test
n Cystic fibrosis DNA detection, blood
203
C H A P T E R
15
Headache
Key Orders*
Order
CCS Terminology
Depression index
ECG, 12-lead
CBC with differential
BMP
PT/PTT
Temporal artery biopsy
ESR
CRP, serum
Sinus X-ray
Depression index
Electrocardiography, 12-lead
CBC with differential
Basic metabolic profile
PT/PTT
Biopsy, temporal artery
Sedimentation rate, erythrocyte
C-reactive protein, serum
X-ray, sinus, paranasal
Sinus CT scan
CT, sinuses
Time to Results—
ED Setting (Stat)
10 min
15 min
30 min
30 min
30 min
1 hr
4 hr
5 hr
30 min (stat),
1 hr (routine)
4 hr (stat),
24 hr (routine)
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
205
15—HEADACHE
Case #85
Location: Office
Chief Complaint: Headache and joint pain
Case introduction
Initial vital signs
Initial history
•A 63-year-old white woman arrives at the office for a 2-day history of headache.
•Temperature: 37.9 degrees C (100.2 degrees F)
•The patient has had worsening headache over the last 2 days. The headache
began suddenly and is located predominantly on the right side. The headache
is associated with severe scalp tenderness causing pain when she rests her
head on a pillow and when she combs her hair. At its worst, the pain is rated
an 8 on a 10-point scale. She has experienced fatigue and joint pain over the
last two weeks. She has not experienced any visual loss or changes.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic with right scalp tenderness on palpation. Vision normal. Eyes,
including funduscopic examination, normal. Hearing normal. Ears, including
pinnae, external auditory canals, and tympanic membranes, normal. Nose and
mouth normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
show right scalp tenderness. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
206
II—CCS CASES BY CHIEF COMPLAINT
Case #85: Temporal Arteritis/Polymyalgia Rheumatica
Keys to Diagnosis
n
n
n
Look for an older patient (>50 years old) with unilateral headache and scalp tenderness.
Other symptoms include fatigue, malaise, jaw pain, visual disturbance, and joint pains. Vital
signs may show fever.
Exam may show scalp tenderness, visual field defects, and decreased joint movements.
Diagnosis is based on American College of Rheumatology (ACR) criteria. A score of three
or more of the following five features is recommended: Age >50, ESR >50 mm/hr, superficial
temporal artery tenderness, temporal headache that is lateralised, positive temporal artery
biopsy. Biopsy is often not needed if other features are present, but if desired, should be
performed within 1 week after the initiation of corticosteroid therapy.
Management
n
n
n
For mild to moderate disease, treat with oral prednisone until symptoms resolve and ESR
returns to normal. If severe symptoms (visual field defects), treat with IV methylprednisolone. Long term steroids require calcium, vitamin D and bisphosphonate (e.g., alendronate)
to prevent steroid-induced osteoporosis.
Because of increased risk of aortic aneurysm, order chest X-ray or chest CT if clinical
suspicion.
Consult ophthalmology and rheumatology, Counseling.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: HEENT, Extremities
•CBC
•ESR
•Temporal artery biopsy
THERAPY
•Prednisone
•Advise patient, side effects of medication
•Calcium carbonate
•Diet, high calcium
•Advise patient, exercise program
•Exam: Additional
•TSH
•CRP
•Rheumatoid factor
•DEXA scan
•Chest X-ray, PA/lateral
•Advise patient, medication
compliance
•Vitamin D
•Alendronate
•Advise patient, no alcohol
•Reassure patient
•Consult, rheumatology
MONITORING
LOCATION
•ESR
•Most patients can be treated as outpatients. Admit to inpatient unit if severe
symptoms or patient unable to provide self-care.
•Management should be instituted within 1 day of simulated time.
TIMING
SEQUENCING
Exam
Orders
Clock
Exam
Orders
Clock
End Orders
HEENT, Extremities, Heart, Lungs, Abdomen ± Complete
CBC, TSH, ESR, CRP, Rheumatoid factor, Prednisone, Advise
patient side effects of medication, Advise patient medication
compliance
Advance clock to reschedule patient when all results are
reported.
HEENT, Extremities
ESR, Temporal artery biopsy (if indicated), Calcium carbonate,
Vitamin D, Alendronate, Diet high calcium, Advise patient
exercise program, Advise patient no alcohol, DEXA scan,
Chest X-ray PA/lateral, Reassure patient, Consult rheumatology
Advance to additional results and case end.
ESR
207
15—HEADACHE
Case #86
Location: Office
Chief Complaint: Headache and Facial pain
Case introduction
Initial vital signs
Initial history
•A 26-year-old African American woman arrives at the office for a 3-day history
of headache and facial pain.
•Unremarkable
•The patient has had worsening infraorbital headache and facial pain over the
last three days. The pain is constant and is rated a 5 on a 10-point scale. Her
symptoms began with an upper respiratory tract infection 2 weeks ago which
was assoicated with clear to yellow nasal discharge. There was some facial
pain at that time which improved but then subsequently worsened over the
last 3 days. She has not had any scalp tenderness, visual loss or shortness of
breath.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities,
Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding her forehead and nose in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose with edematous mucosa and yellow nasal
discharge. Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
208
II—CCS CASES BY CHIEF COMPLAINT
Case #86: Acute Sinusitis
Keys to Diagnosis
n
n
n
Look for a patient with infraorbital headache or facial pain present more than 10 days after
onset of symptoms of an upper respiratory tract infection. Additional symptoms include
purulent rhinorrhea, decreased sense of smell, and facial swelling. Vital signs may show fever.
Examination may show facial pain or edematous nasal mucosa with nasal discharge.
Diagnosis is based primarily on history. Labs and imaging, including sinus X-ray or CT is
generally not needed initially unless treatment is ineffective.
Management
n
n
n
Symptomatic treatment is preferred for mild disease. Alpha-adrenergic vasoconstrictors
(e.g., pseudoephedrine) can be used for 2 weeks to help with sinus drainage.
Because most cases are caused by a virus, antibiotics are generally discouraged. For moderate
to severe disease or if symptoms persist, consider amoxicillin or erythromycin.
Reassurance.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: HEENT
THERAPY
•Exam: Additional
•Sinus X-ray or CT (if initial treatment not effective)
•Antibiotic (if severe or persistent disease)
•Reassure patient
•Pseudoephedrine
•None
•Most cases can be treated as an outpatient
•Management should be instituted within 1 day of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Exam
Orders
Clock
End Orders
HEENT, Heart, Lungs, Abdomen ± Complete
Reassure patient, Pseudoephedrine, Counsel patient
Advance clock to reschedule patient in 1 week.
HEENT
Reassure patient.
Advance to additional results and case end.
None
209
15—HEADACHE
Case #87
Location: Office
Chief Complaint: Unilateral headache
Case introduction
Initial vital signs
Initial history
•A 55-year-old white woman arrives at the office for a 1-day history of rightsided frontal headache.
•Unremarkable
•The patient has experienced a tingling and throbbing type of pain that
began yesterday and now is more of a burning and stabing type of pain.
The pain is located on the right forehead extending to the scalp in a linear
pattern. The pain is constant and is rated 7 on a 10-point scale. The pain
has caused her to have difficulty sleeping. She has never experienced this
type of pain before. There is no visual loss, nausea, jaw pain, fatigue or
joint pain.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding her right forehead in discomfort.
Skin
Normal turgor. Mild rash on the right forehead and temporal region. Hair and nails
normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic with mild rash in the temporal region. Vision normal. Eyes,
including funduscopic examination, normal. Hearing normal. Ears, including
pinnae, external auditory canals, and tympanic membranes, normal. Nose and
mouth normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
210
II—CCS CASES BY CHIEF COMPLAINT
Case #87: Herpes Zoster (Shingles)
Keys to Diagnosis
n
n
n
Look for a patient who presents with unilateral temporal pain with headache. Unlike giant
cell arteritis, there is no joint pain, visual disturbances, jaw pain, or fatigue. Often symptoms
begin with a rash that may appear like contact dermatitis.
On exam, the classic vesicles may not be present on initial exam. Look for rash, then vesicles
in a dermatome distribution a few days after initial presentation.
Diagnosis is based on history and exam. Workup should rule out other causes, such as giant
cell arteritis. Confirmation via tzanck smear, PCR or culture is generally not needed unless
the diagnosis is unclear.
Management
n
n
n
n
Episodes of herpes zoster are generally self-limited in immunocompetent patients and
­resolve on their own. Treatment can reduce duration of symptoms and chronic sequelae,
particularly in immunocompromised patints and people age >50.
Treat pain with NSAIDs, narcotic or Gabapentin. Antivirals (e.g., valacyclovir) can reduce
pain, inflammation, and vesicle formation if begun within 48 hours of onset of rash.
Varicella vaccine reduces severity and pain caused by herpes zoster in most patients.
Cold compresses are useful to break vesicles and remove serum and crust.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Skin, HEENT
THERAPY
•Exam: Additional
•CBC
•ESR
•Counsel patient
•Reassure patient
•NASAIDs or Gabapentin for pain
•Valacyclovir, oral
•Compresses, cold
•Varicella virus vaccine
•Monitor clinical exam for development of vesicles.
•Immunocompetent patients can be treated as outpatients.
•Management should be instituted within 2 days of simulated time. The
diagnosis may not be clear on the first office visit.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Exam
Orders
Clock
End Orders
Skin, HEENT, Extremities, Heart, Lungs, Abdomen ± Others
NSAIDs, CBC, ESR
Advance clock to reschedule patient the next day.
Skin, HEENT
Valacyclovir, Varicella vaccine, Cold compresses, Counsel
patient, Reassure patient
Advance to additional results, patient updates and case end.
None
211
15—HEADACHE
Case #88
Location: Office
Chief Complaint: Generalized headache and difficulty sleeping
Case introduction
Initial vital signs
Initial history
•A 73-year-old white woman arrives at the office with her daughter for a
2-month history of headache.
•Unremarkable
•The patient has experienced a generalized headache over the last two
months. The pain is intermittent and is rated a 4 on a 10-point scale. She
also describes difficulty sleeping and tiredness during that time period. She
has been feeling sad for over 18 months since the loss of her spouse. Her
daughter says she is uninterested in her normal activities and does not leave
the house much. She has reduced appetite with 15-lb weight loss over the
last 5 months.
•Past medical history of three childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities,
Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, elderly female; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple; no
masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and peripheral
Cardiovascular
pulses normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
212
II—CCS CASES BY CHIEF COMPLAINT
Case #88: Depression
Keys to Diagnosis
n
n
n
Look for a patient who presents with a several-month history of intermittent generalized
headache, tiredness, anorexia, weight loss, difficulty sleeping, or difficulty concentrating.
History shows significant loss in the past 1 to 2 years (loss of spouse or child) and loss of
interest in normal activities, as well as decreased socialization with friends.
Exam is generally unremarkable.
Diagnosis is based on history and depression index. Workup should include ruling out other
potential diagnoses causing fatigue.
Management
n
n
n
Selective serotonin reuptake inhibitors (SSRIs) are considered first line (e.g., fluoxetine).
Psychotherapy with psychologist or psychiatrist.
Counseling with attention to suicide prevention.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Depression index
THERAPY
•CBC
•Vitamin B12, serum
•BMP
•LFT
•TSH
•Urinalysis
•Advise patient, no alcohol
•Counsel patient
•Reassure patient
•Advise patient, suicide contract
•Fluoxetine
•Psychotherapy, psychologist provider
•None
•Most patients can be treated as outpatients unless risk of suicide.
•Management should be instituted within 4 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Skin, Neuro ± Additional
Depression index
Advance clock to results of depression index.
CBC, BMP, LFT, TSH, Urinalysis, Vitamin B12 serum, Advise
patient suicide contract, Advise patient no alcohol, Counsel
patient, Reassure patient
Advance clock to reschedule patient after results of studies.
SSRI (e.g., Fluoxetine), Psychotherapy (psychologist provider)
Advance to additional results, patient updates and case end.
None
213
15—HEADACHE
Case #89
Location: Emergency Department
Chief Complaint: Severe headache
Case introduction
Initial vital signs
Initial history
•A 55-year-old white woman is brought to the emergency department by her
husband for severe headache over the past 3 hours.
•Blood pressure, systolic: 228 mm Hg
•Blood pressure, diastolic: 126 mm Hg
•The patient has had worsening headache over the last 3 hours. The
headache is in the occipital region and rated a 8 on a 10-point scale. The
headache is associated with visual blurriness and she has had difficulty
concentrating and answering questions. She vomited once prior to arrival
and she is now mildly short of breath. She has not experienced chest pain,
loss of consciousness or localized weakness. She has missed several regular
appointments to see her primary care physician over the last three years.
•Past medical history includes hypertension treated with hydrochlorothiazide.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; holding the back of her head in moderate
distress.
HEENT/Neck
Normocephalic. Vision normal. Funduscopic examination shows retinal
hemorrhage and papilledema. Hearing normal. Ears, including pinnae,
external auditory canals, and tympanic membranes, normal. Nose and
mouth normal. Pharynx normal. Neck supple; no masses or bruits; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. Mild bilateral rales at the bases.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses strong. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. Mild 1+
peripheral edema. Peripheral pulses strong. No joint deformity or warmth;
full range of motion. Spine examination normal.
Neuro/Psych
Neurologic exam difficult to assess as patient has difficulty answering
questions. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
214
II—CCS CASES BY CHIEF COMPLAINT
Case #89: Hypertensive Emergency
Keys to Diagnosis
n
n
n
The diagnosis is usually apparent from the initial vital signs showing high blood pressure
(>200/120). In addition, look for symptoms of end organ damage including, shortness of
breath, headache, chest pain, blurred vision, peripheral edema and oliguria.
Exam may show abnormalities on funduscopy, pulmonary rales, or peripheral edema.
Diagnosis is made on blood pressure measurement. Look for signs of renal failure, MI, CHF,
aortic dissection and cerebral hemorrhage.
Management
n
n
n
ABCs - Monitoring of vital signs, Monitor for end-organ damage.
Antihypertensive (e.g., labetalol) to rapidly reduce blood pressure, if signs of end organ
damage or BP >200/120. Switch to oral anti-hypertensives once a more normal BP level
­obtained.
Counseling once patient stabilized.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•CBC
•BMP
•Urinalysis
•Troponin I, serum
•Head CT without contrast
•Oxygen
•Antihypertensive (e.g., labetalol)
•Blood pressure monitor,
continuous
•ECG, 12-lead
•LFT
•BNP
•Chest X-ray, portable
•Intravenous access
•Cardiac monitor
•Pulse oximetry
•Urine output
•Manage in the ED and ICU until stable blood pressure.
•Therapy should be instituted within 1 hour of simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Exam
Location
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
HEENT, Chest, Heart, Abdomen, Neuro
Oxygen, Intravenous access, BMP, CBC, Urinalysis, ECG,
Troponin, BNP, Head CT, Chest X-ray portable
Advance to results, about 30 minutes.
Labetalol, Urine output
Advance to additional results and patient update.
Vital signs
Interval/follow up and Complete exam
Change to ICU.
Advance to additional patient updates and case end.
Reassure patient, Counsel patient
15—HEADACHE
215
Headache—Key Points
n
n
ost cases of headache can be diagnosed on history and exam.
M
Important orders to keep in mind if you get a CCS case of a patient who presents with
headache include:
n ESR
n Temporal artery biopsy
n Depression index
n Head CT
C H A P T E R
16
Bruising
Key Orders*
Order
CCS Terminology
Abuse, domestic, safety plan
Eldercare
CBC with differential
PT/PTT
Bleeding time
Bone marrow aspiration
Advise patient, safety plan
Consult, social services
CBC with differential
PT/PTT
Bleeding time
Aspirate, bone marrow
Bone marrow biopsy, needle
Biopsy, bone marrow, needle
Factor I, plasma
Factor II, plasma
Factor V, plasma
Factor VII, plasma
Factor VIII, plasma
Factor VIIIR antigen, plasma
Factor IX, plasma
Factor X, plasma
Factor XI, plasma
Factor XII, plasma
Factor XIII, plasma
Platelet retention
Ristocetin cofactor
Platelet antibody, plasma
Fibrinogen, plasma
Factor II, plasma
Factor V, plasma
Factor VII, plasma
Antihemophilic factor, plasma
Antigen, von Willebrand factor, plasma
Factor IX, plasma
Factor X, plasma
Factor XI, plasma
Factor XII, plasma
Factor XIII, plasma
Platelet adhesiveness
Platelet aggregation
Antibody, platelet, plasma
Time to Results—ED
Setting (Stat)
5 min
15 min
30 min
30 min
1 hr
20 min (to perform),
3 hr (for results)
20 min (to perform),
3 hr (for results)
2 hr
2 hr
2 hr
2 hr
2 hr
7 days
2 hr
2 hr
2 hr
2 hr
2 hr
4 hr
6 hr
24 hr
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
217
16—BRUISING
Case #90
Location: Emergency Department
Chief Complaint: Bruising
Case introduction
Initial vital signs
Initial history
•A 4-year-old boy is brought to the emergency department by his mother for
multiple bruises on his body.
•Unremarkable
•The mother noticed multiple bruises his chest, back, and arms developing over
the past 2 days. There is no history of trauma or injuries to the sites. He had an
upper respiratory infection 3 weeks ago with cough, runny nose, fever, chills,
and fatigue accompanied by a rash that resolved on its own about 1 week ago.
He has no prior visits to the emergency department.
•No past medical history of significant illnesses or injuries.
•Developmental history, family history, and review of systems unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
218
II—CCS CASES BY CHIEF COMPLAINT
Case #90: Immune Thrombocytopenic Purpura (ITP)
Keys to Diagnosis
n
n
n
Look for a child or young adult who presents with recent onset bruising or bleeding—nose
bleed, vaginal bleeding, or heme-positive stools. No family history of bleeding.
Examination may show petechiae, bruising or mucosal bleeding.
CBC shows low platelet count. PT/PTT is typically normal. Bleeding time is no longer
routinely done, but it would be elevated if ordered. Rule out other causes in the differential,
such as von Willebrand disease. Platelet antibody, bone marrow aspirate and biopsy are not
mandatory but often ordered, particularly if steroids are planned.
Management
n
n
Control bleeding if needed (e.g., nasal packing if nose bleed).
Treatment varies with platelet count:
n PLT >30,000, asymptomatic: observation and monitoring of platelet count.
n PLT <20,000 or PLT< 50,000 with bleeding: prednisone, oral.
n If serious bleeding needing emergent surgery: methylprednisone IV, IV immunoglobulin,
and/or platelet transfusion.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Skin, HEENT/Neck, Neuro/Psych
•CBC with differential
•PT/PTT
•Platelet antibody, plasma
THERAPY
•Bleeding time
•Bone marrow aspirate
•Bone marrow biopsy
•Ristocetin cofactor
•Factor VIII, plasma
•Von Willebrand factor antigen
•Consult hematology/oncology
•Reassure patient
•Counsel parent
•Medications (Steroids if above criteria met)
•CBC daily
•Admit to inpatient unit if severe thrombocytopenia, bleeding or anemia.
•Management should be instituted within 1 day of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
End Orders
Complete
CBC, PT/PTT
Advance to results.
Bone marrow aspirate, Bone marrow biopsy, Ristocetin cofactor,
Factor VIII plasma, von Willebrand factor antigen, Platelet
antibody.
Advance clock to results of bone marrow.
Consult pediatric hematology/oncology, Steroids (if indicated),
Reassure, Counsel parent
Admit to inpatient unit if indicated.
Advance to additional patient updates and case end
CBC daily
219
16—BRUISING
Case #91
Location: Emergency Department
Chief Complaint: Multiple bruises
Case introduction
Initial vital signs
Initial history
•An 81-year-old woman is brought to the emergency department by a neighbor for multiple bruises on her body.
•Unremarkable
•The patient is brought to emergency department by her neighbor after she
fell down a flight of stairs four hours ago. She has bruising on her arms, back,
chest and legs of varying ages. She complains of pain in her arms, back and
legs. This is her fourth visit to the emergency department with bruising or
falling in the last two years. The neighbor is disruptive with medical staff and is
demanding that she be given pain medications so they can go home.
•Past medical history of three normal childbirths. She has a history of arthritis
and reflux disease.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, elderly female; in no apparent distress.
Skin
Normal turgor. Multiple bruises of varying ages on her arms, legs, back and
chest. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
220
II—CCS CASES BY CHIEF COMPLAINT
Case #91: Elder Abuse
Keys to Diagnosis
n
n
n
Look for an older patient with multiple bruises in many areas and other injuries such as
fractures. Often the history shows multiple prior visits to the emergency department. There
may be a disruptive family member or acquaintance who accompanies the patient. Generally,
there is no family history of bleeding.
Examination confirms the extent of bruising and may show other injuries.
Diagnosis is based mainly on history and exam. Basic labs, such as CBC and PT/PTT, rule
out an underlying coagulopathy. Imaging studies of any painful areas may show additional
and old injuries.
Management
n
n
n
Counseling and social services consult. The history of abuse may be given after consult.
If needed, any pain relief and treatment of injuries.
Admit to inpatient unit for safety.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Extremities, HEENT, Skin
•Exam: Additional
•CBC
•X-rays of any injured areas
•PT/PTT
•Eldercare (Consult, social services)
•Counsel patient
•Advise patient, safety plan
•Acetaminophen
•Advise patient, restraining order
•Reassure patient
•Not important for this case.
•Change location to inpatient unit for patient safety. Do not send the patient
home.
•The diagnosis and management should be performed within 6 hours of
simulated time.
Exam
Orders
Clock
Orders
Clock
Location
Exam
Clock
End Orders
Skin, HEENT, Abdomen, Genitalia, Extremities ± Others
CBC, PT/PTT, X-rays of injured areas, Acetaminophen
Advance to results.
Counsel patient, Advise patient safety plan, Consult social
services, Advise patient restraining order, Reassure
patient, Cast extremity (if fracture present)
Advance to results of consult social services
Change to inpatient unit
Interval/follow up
Advance to additional patient updates and case end.
None
221
16—BRUISING
Case #92
Location: Emergency Department
Chief Complaint: Bruising with family history
Case introduction
Initial vital signs
Initial history
•An 8-month-old boy is brought to the emergency department by his mother
for a bulging bruise on his lower back.
•Unremarkable
•The bruise was noticed about 2 hours ago and has progressively worsened. The child has had difficulty crawling and has been fussy. The mother
has noticed occasional small bruises on the knees and elbows over the past
few days related to attempts at crawling.
•Past medical history does not show any significant illnesses or hospitalizations. The patient was born by normal vaginal delivery without complications.
•Family history includes a maternal uncle and grandfather with bleeding
problems. There is no history of bruising or bleeding in the patient’s older
5 year old sister or parents.
•Developmental history and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
•Complete
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. Large, palpable, oval-shaped ecchymosis from the lower back to the
buttocks. Small bruises on the knees and elbows. Hair and nails normal.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
MANAGEMENT
Orders
•CBC with differential, PT/PTT, Urinalysis
Results: Time course: Advance clock to results of studies
Results (Pertinent Findings)
CBC with differential
Hemoglobin 10 g/dL (nl = 11–13)
PT/PTT
PT: 10.0 sec (control <12.0)
INR: 1.1 (nl = 1.0-1.3)
PTT: 390 sec (control <28.0)
What is the suspected diagnosis, and what are the next steps in management?
222
II—CCS CASES BY CHIEF COMPLAINT
Case #92: Hemophilia
Keys to Diagnosis
n
n
n
Look for a young male patient with bleeding; because hemophilia A and B are X-linked
recessive, only males are affected. Common presentation is excessive bleeding after a dental
procedure, but symptoms can include bleeding in joints, dark-colored stools, hematomas,
bruises, and hematuria. Family history is typically positive in a male relative.
Examination shows extent of bruising or bleeding and may show signs of anemia.
Diagnosis is based on prolonged PTT and reduced factor VIII (hemophilia A) or factor IX
(hemophilia B) levels. PT, fibrinogen, and bleeding time are generally normal. CBC may
show anemia. Rule out von Willebrands disease.
Management
n
n
Acute therapy: factor VIII concentrate to control spontaneous and traumatic hemorrhage.
DDAVP for minor surgical procedures. Factor IX concentrates in hemophilia B.
Chronic therapy: avoid contact sports, avoid aspirin and NSAIDs, hepatitis vaccination.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Extremities/Spine, Skin,
•Urinalysis
•CBC with differential
•Factor XI, plasma
•PT/PPT
•Von Willebrand factor antigen
•Factor VIII, plasma
•Ristocetin cofactor
•Factor IX, plasma
•Factor VIII, therapy
•Consult, pediatric hematology/
•Counsel parent
oncology
•Medic alert bracelet
•Type and screen, blood
•PT/PPT
•Admit to inpatient unit if severe symptoms or requires transfusion.
•Management should be instituted within 4 hours of simulated time.
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
Complete
CBC with differential, PT/PPT, Urinalysis
Advance to next available set of results.
Change to inpatient unit if indicated.
Factor VIII, Factor IX, Von Willebrand factor antigen,
Ristocein cofactor.
Advance to Factor results.
Factor VIII therapy, Consult pediatric hematology/oncology,
Counsel parent
Advance to additional results and patient updates.
PT/PTT, Medic alert bracelet
223
16—BRUISING
Bruising—Key Points
n
n
ook for key features in the history to help differentiate abuse from a pathologic cause of
L
bruising (Table 16-1):
n Family history of bruising
n Disruptive family members
n Bruises in multiple sites
n Previous visits to the emergency department
Most cases of bruising or bleeding can be triaged with basic labs that provide results in
30 minutes:
n CBC with differential
n P T/PTT
TABLE 16-1 n Common Disorders Seen in Patients Who Present with Bruising or Bleeding
Diagnosis
Platelet
Count
PT
PTT
Additional Studies
ITP
Low
Normal
Normal
Hemophilia
Normal
Normal
High
Platelet antibody
Bone marrow biopsy
Factor VIII activity
Factor IX activity
Abuse
Normal
Normal
Normal
Von Willebrand
disease
Normal
Normal
High or
normal
Basic Treatment
­Options
Steroids
IVIG
DDAVP
Factor VIII or IX
concentrate
Consult, social services Admit to inpatient
unit
Advise patient,
safety plan
Factor VIII activity
DDAVP
Factor VIII
Ristocetin cofactor
concentrate
Von Willebrand factor
antigen
C H A P T E R
17
Routine Health Exam
Key Orders*
Order
CCS Terminology
Blood pressure
Blood pressure
Pregnancy test, urine, qualitative
hCG, beta, urine, qualitative
ECG, 12-lead
Electrocardiography, 12-lead
HIV antibody test, rapid, blood
Urinalysis
Antibody, rapid HIV test, blood
Urinalysis
Chest X-ray, PA/lateral
X-ray, chest, PA/lateral
BMP
Basic metabolic profile
Fasting blood glucose
CBC with differential
Glucose, serum, fasting
CBC with differential
Colonoscopy
Colonoscopy
EGD
Endoscopy, upper gastrointestinal
LFT
Uric acid, blood
Cardiac catheterization,
angiocardiography
Liver function panel
Uric acid, serum
Angiocardiography, right and left
heart
GTT, 1-hour
GTT, 3-hour
PFT
Fasting lipid profile
A1C hemoglobin
Urine cytology
ANA, serum
Bladder tumor, transurethral resection
Cystoscopy
Sleep apnea study
TSH, serum
TSH, serum, ultrasensitive
Glucose tolerance test, 1-hour
Glucose tolerance test, 3-hour
Pulmonary function tests
Lipid profile
Hemoglobin A1c, blood
Cytology, urine
Antibody, antinuclear, serum
Transurethral resection, bladder tumor
Cystourethroscopy
Cardiopulmonary sleep study
Hormone, thyroid-stimulating, serum
Hormone, thyroid-stimulating, serum
ultrasensitive
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
Office Setting
1 min (stat),
1 min (routine)
5 min (stat),
20 min (routine)
15 min (stat),
30 min (routine)
20 min
30 min (stat),
6 hr (routine)
30 min (stat),
4 hr (routine)
30 min (stat),
2.5 hr (routine)
1 hr
1 hr (stat),
4 hr (routine)
1 hr (stat),
24 hr (routine)
1 hr (stat),
2 hr (routine)
2.5 hr
3 hr
3 hr (stat),
24 hr (routine)
3 hr
5 hr
8 hr
24 hr
24 hr
24 hr
24 hr
24 hr
26 hr
2 days
2 days
2 days
17—ROUTINE HEALTH EXAM
225
Case #93
Location: Office
Chief Complaint: None; routine exam
Case introduction
Initial vital signs
Initial history
•An 18-year-old African American man arrives at the office for a routine health visit.
•Blood pressure, systolic: 152 mm Hg
•Blood pressure, diastolic: 92 mm Hg
•Height: 175.2 cm (69.0 in)
•Weight: 92.5 kg (204.0 lb)
•Body mass index: 30.1 kg/m2
•The patient is about begin college in a few months and is required to have routine health screening before starting. He has no complaints other than intermittent acne he gets on the face. He is not sexually active, and his vaccinations
are up to date. He smokes a few cigarettes on weekends and rarely drinks
alcoholic beverages.
•Past medical history is unremarkable.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, overweight; in no apparent distress.
Skin
Normal turgor. Mild acne on the face. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
226
II—CCS CASES BY CHIEF COMPLAINT
Case #93: Hypertension, Primary; Obesity
Keys to Diagnosis
n
n
n
ook for a teenage or young adult patient who presents for a routine health exam. Vital signs
L
show elevated blood pressure and increased BMI if obesity present.
Examination is generally unremarkable in primary hypertension. Look for signs of ­secondary
hypertension, such as abdominal bruit (renal artery stenosis), heart murmur (aorta ­coarctation),
moon facies & truncal obesity (Cushing’s syndrome), malar rash (systemic lupus).
Confirm hypertension with repeat blood pressure. Diagnosis focuses on evaluating for the presence of end organ damage, looking at cardiovascular risk factors and ruling out ­secondary causes
of hypertension. More specific studies for pheochromocytoma (Urine ­catecholamines), Cushing’s
syndrome (dexamethasone suppresion test), Renal artery stenosis (renal artery angiogram), Turner syndrome (karyotype), hyperthyroidism (TSH), adrenal insufficiency (plasma cortisol, ACTH
stimulation test) and systemic lupus (ANA) will depend on the individual patient.
Management
n
n
n
ifestyle modifications are the cornerstone of treatment for hypertension and obesity—
L
weight loss diet, exercise, along with counseling regarding smoking, alcohol, and safe sex.
Medications (e.g., beta blockers or diuretics) should be initiated if blood pressure is ­unresponsive
to lifestyle changes or if end-organ damage is present.
Symptomatic treatment of any other complaints (e.g., benzoyl peroxide for acne).
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Complete
•CBC
•Blood pressure
•Uric acid
•BMP
•TSH, serum
•ECG, 12-lead
•Urine culture
•Urinalysis
•Urine toxicology screen
•Lipid profile
•Renal ultrasound
•Fasting blood glucose
•Advise patient, exercise program
•Reassure patient
•Advise patient, no smoking
•Advise patient, no alcohol
•Weight loss diet
•Diet, low sodium
•Diet, low fat
•Blood pressure should be taken two times at each visit.
•Monitor weight at each visit.
•Most routine cases can be managed as outpatients.
•Management should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Orders
Clock
End Order
Complete
Blood pressure
Advance to repeat blood pressure result.
CBC, BMP, ECG, Lipid profile, Fasting glucose, TSH, Uric acid,
Urinalysis, Urine culture, Renal ultrasound, Urine toxicology screen
Reschedule for follow-up after all results are reported.
Blood pressure
Advance to blood pressure result.
Weight loss diet, Diet low sodium, Diet low fat, Advise patient
exercise program, Advise patient no smoking, Advise patient no
alcohol, Advise patient safe sex, Reassure patient
Reschedule for follow-up every 1 to 2 months for patient updates
and case end.
None
17—ROUTINE HEALTH EXAM
227
Case #94
Location: Office
Chief Complaint: None; medical clearance for surgery
Case introduction
Initial vital signs
Initial history
•A 33-year-old white woman arrives at the office with her husband for a
­preoperative evaluation.
•Height: 162.5 cm (64.0 in)
•Weight: 112.5 kg (248.0 lb)
•Body mass index: 42.6 kg/m2
•The patient is scheduled to undergo gastric bypass surgery and arrives at the
office for medical clearance. She has struggled with weight loss for numerous
years and has decided to undergo surgery. Over the last several months, she
occasionally gets short of breath with walking or strenuous activity. She has
also experienced increasing weakness over the last month and had an episode
of syncope two weeks ago. She has attributed the symptoms to her obesity
and feels the surgery will relieve her symptoms. She also describes increased
daytime sleepiness and difficulty sleeping over the last three months. Her
­husband complains of her snoring during the night. She is married and sexually
­active with only her husband. There is no history of smoking or alcohol use.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, obese; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. S4 heart sound present with holosystolic murmur. Central
and peripheral pulses normal. Mild jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Abdomen obese. Bowel sounds normal; no bruits. No masses or
tenderness. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. Mild 1+
peripheral edema. Peripheral pulses normal. No joint deformity or warmth;
full range of motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
228
II—CCS CASES BY CHIEF COMPLAINT
Case #94: Pulmonary Hypertension; Obstructive sleep
apnea
Keys to Diagnosis
n
n
n
For pulmonary hypertension, look for a patient that presents with non-specific symptoms
that can include: exertional dyspnea, fatigue, syncope, or abdominal distention from ascites.
Obstructive sleep apnea generally presents in an obese person with snoring, difficulty sleeping and daytime sleepiness. Vital signs may show elevated BMI if obesity, but otherwise are
generally unremarkable.
On exam, look for jugular venous distention, loud P2, S4, systolic murmur or peripheral
edema in pulmonary hypertension.
The diagnosis focuses on determining if the pulmonary hypertension is primary or ­secondary
to another medical problem. Abnormal studies in pulmonary hypertension can include ECG,
Chest X-ray and echocardiography. Evaluation of secondary causes of pulmonary hypertension include sleep apnea study (­polysomnography), ANA for connective tissue disease, TSH
for thyroid abnormalities and D-dimer. If ­secondary causes are ruled out, cardiac catheterization confirms increased pulmonary pressure in primary pulmonary hypertension.
Management
n
n
For secondary pulmonay hypertension, treat the underlying condition. For sleep apnea, treat
with CPAP, weight loss and avoiding smoking and alcohol.
For primary pulmonary hypertension, treat with medications (diuretics, vasodilators, coumadin), counseling (diet - low sodium, avoid sports, avoid pregnancy), and oxygen if needed.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Heart, Lungs, Extremities
•ECG, 12-lead
•Chest X-ray, PA/lateral
•PT/PTT
•Sleep apnea study
•Echocardiography
THERAPY
•CPAP
•Weight loss diet
•CBC
•Pulmonary function tests
•BMP
•TSH
•ANA
•LFT
•D-dimer
•Advise patient no smoking
•Advise patient, no alcohol
•Counsel patient
•Reassure patient
MONITORING
LOCATION
TIMING
•Pulse oximetry to assess need for oxygen.
•Most cases can be treated as an outpatient.
•Management should be instituted within 4 days of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
ECG, Chest X-ray PA/lateral, Pulse oximetry
Advance to ECG, chest X-ray results in office.
Echocardiography, CBC, PT/PTT, BMP, LFT, TSH, ANA, D-dimer,
Pulmonary function tests, Sleep apnea study
Advance clock to reschedule patient when all results are reported.
CPAP, Weight loss diet, Advise patient no smoking, Advise patient
no alcohol, Counsel patient, Reassure patient
Advance clock for patient updates and case end.
None
17—ROUTINE HEALTH EXAM
229
Case #95
Location: Office
Chief Complaint: None; routine follow-up prenatal exam
Case introduction
Initial vital signs
Initial history
•A 29-year-old African American woman at 26 weeks’ gestation arrives at the
office for a routine prenatal evaluation.
•Unremarkable
•The patient is G1 P0 in her 26th week of gestation and has arrived for a
routine visit. She recently had a 1-hour glucose tolerance test that showed a
result of 155 mg/dL (normal range <130 mg/dL). She has no symptoms, and
her other prenatal study results have been normal. She is sexually active with
only her husband. She does not smoke cigarettes, drink alcoholic beverages,
or use illicit drugs.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished, pregnant; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Gravid. Fundal height, 26 cm. Fetal heart rate, 155 beats/min. Bowel
sounds normal. No tenderness. Liver and spleen not palpable.
Genitalia
Normal labia. No vaginal lesions. Cervix nondilated, not effaced. No adnexal
masses.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
230
II—CCS CASES BY CHIEF COMPLAINT
Case #95: Gestational Diabetes Mellitus
Keys to Diagnosis
n
n
n
ook for a pregnant patient who presents with elevated screening glucose tolerance test
L
result. Risk factors include obesity, hypertension, family history, and increasing weight.
Exam is generally unremarkable.
All pregnant women should be screened from 24 to 28 weeks’ gestation with a 1-hour
glucose tolerance test. If >130 mg/dL, a 3-hour glucose tolerance test is ordered. If two values
of the 3-hour test are elevated, the diagnosis is made.
Management
n
n
n
iet control is first-line treatment—diabetic diet with high fiber, low fat, and low sugar.
D
If diet trial fails, use glyburide and then insulin.
Monitor weight and order fetal ultrasound at 36 to 38 weeks’ gestation for macrosomia.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Complete
•Hemoglobin A1C
•Glucose tolerance test, 3-hour
•BMP
•Urinalysis
•TSH, serum
•Advise patient, home glucose monitoring
•Diet, high fiber
•Advise patient, exercise program
•Diet, low fat
•Diet, diabetic
•Glyburide (if diet fails)
•Monitor weight on subsequent visits
•Most patients can be managed as outpatient.
•Diagnosis and management should be instituted within 3 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Order
Complete
Glucose tolerance test 3-hour, Urinalysis
Reschedule patient next day for result.
Hb A1c, BMP, TSH, Diet diabetic, Advise patient home glucose
monitoring, Advise patient exercise program, Counsel patient,
Reassure patient
Reschedule for follow-up in about 1 month.
Reassure patient
Advance clock to additional results and case end.
Fetal ultrasound at 36-38 weeks gestation.
17—ROUTINE HEALTH EXAM
231
Case #96
Location: Office
Chief Complaint: None; routine exam
Case introduction
Initial vital signs
Initial history
•A 47-year-old white man arrives at the office for a routine health exam.
•Unremarkable
•The patient has not seen a doctor in more than 5 years and arrives for
a routine screening exam for a new job as a delivery driver. He has no
complaints. He is sexually active with his wife only. He has a 25-year history
of smoking one pack of cigarettes a day. He occasionally drinks 1 or 2
alcoholic drinks on weekends. There is no history of illicit drug use.
•Past medical history of urinary tract infection 6 months ago.
•Family history unremarkable.
•Review of systems shows a 10-lb weight loss over the past 3 months.
Occasional episodes of red-tinged urine not associated with pain.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination results normal.
What is the suspected diagnosis, and what are the next steps in management?
232
II—CCS CASES BY CHIEF COMPLAINT
Case #96: Bladder Cancer
Keys to Diagnosis
n
n
n
Look for a patient that presents with subtle findings. Symptoms can include: painless hematuria, dysuria, urinary frequency, abdominal pain, or bone pain if metastases. Risk factors include
smoking and diets rich in beef or animal fat.
Exam is unremarkable.
Urinalysis showing hematuria will be the first clue to diagnosis. Urine cytology and
Cystoscopy (with automatic urology consult) is diagnostic.
Management
n
n
n
Transurethral resection of bladder tumor is first line treatment to diagnose, stage and treat
visible tumors.
If muscle invasion found, the treatment typically is cystectomy (not offered in CCS) or consult urology.
Counseling regarding cancer diagnosis, advise no smoking, reassurance.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Complete
•CBC
•Urinalysis
•BMP
•Urine cytology
•LFT
•Cystoscopy
•Urine culture
•Transurethral resection, bladder tumor
•Advise patient, cancer
•Consult, urology
diagnosis
•Advise patient, no smoking
•Reassure patient
•Follow-up after resection with cystoscopy in 3 months.
•Office, manage as outpatient.
•Diagnosis and management should be instituted within 3 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Order
Complete
Urinalysis
Advance clock to results of urinalysis
Urine cytology, Cystoscopy, CBC, BMP, LFT, Urine culture, Advise
patient no smoking
Reschedule for follow-up after all results are reported.
Transurethral resection bladder tumor, Consult urology, Advise
patient cancer diagnosis, Reassure patient
Advance clock to additional results, patient updates and case end.
None
17—ROUTINE HEALTH EXAM
233
Routine Health Exam—Key Points
n
I t is very unlikely you will get a “normal” patient with no abnormality. If you do get a patient
with no chief complaint who presents for a routine screening examination, look for the
following:
n Increased weight/BMI for obesity
n History of weight loss for underlying cancer
n Smoking history
n Increased blood pressure for systemic hypertension
n Subtle findings suggestive of pulmonary hypertension
n Menstrual history suggesting an undiagnosed pregnancy
n Lab studies to consider include:
n Lipid profile
n CBC
n Fasting blood glucose
n hCG, beta, urine, qualitative
n TSH
n Urinalysis
C H A P T E R
18
Miscellaneous Internal
Medicine Cases
Key Orders*
Order
CCS Terminology
Time to Results—
ED Setting (Stat)
Chest X-ray, portable
CBC with differential
BMP
Urinalysis
Head CT without contrast
Lactic acid, blood
Urine sodium
Urine osmolality
Carotid Doppler
Carotid angiography
Urine creatinine
Clearance, creatinine
Urine culture
Blood culture
Carotid MRA
X-ray, chest, AP, portable
CBC with differential
Basic metabolic profile
Urinalysis
CT, head, without contrast
Lactate, serum
Sodium, urine
Osmolality, urine
Doppler, carotid arteries
Angiography, carotid arteries
Creatinine, 24-hour urine
Creatinine clearance
Bacterial culture, urine
Bacterial culture, blood
MRA, carotid arteries
10 min
30 min
30 min
30 min
30 min
1 hr
1 hr
1 hr
2 hr
3 hr
24 hr
24 hr
24 hr
30 hr
3 days
Order
CCS Terminology
Time to Results—
Office Setting
ECG, 12-lead
Echocardiography
Thyroid ultrasound
Thyroid scan
Thyroid hormone, T4, serum, total
Holter monitor
Thyroid biopsy
TSH, serum
TSH, serum, ultrasensitive
Free T4
Free T3, serum
Thyroid hormone, T3, serum, total
Electrocardiography, 12-lead
Echocardiography
US, thyroid
Scan, thyroid
Thyroxine, serum, total
Echocardiography, ambulatory
Biopsy, thyroid
Hormone, thyroid stimulating, serum
Hormone, thyroid stimulating, serum,
ultrasensitive
Thyroxine, serum, free
Triiodothyronine, serum, free
Triiodothyronine, serum, total
RAI uptake, thyroid
Thyroid uptake
Thyroid autoantibodies, serum
Antibody, thyroid, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
15 min (stat),
30 min (routine)
30 min (stat),
4 hr (routine)
8 hr
6 hr
1 day 15 min
2 days
2 days
2 days
2 days
2 days
2 days
2 days
2 days
4 days
18—MISCELLANEOUS INTERNAL MEDICINE CASES
235
Case #97
Location: Office
Chief Complaint: Weight loss
Case introduction
Initial vital signs
Initial history
•A 46-year-old African-American woman arrives at the office for a 4-month
history of weight loss.
•Pulse: 118 beats/min
•Height: 162.5 cm (64.0 in)
•Weight: 52.1 kg (115.0 lb.)
•Body mass index: 19.7 kg/m2
•The patient has experienced a 15-lb weight loss over the past 4 months
despite an increase in appetite. She also notes increased anxiety, irritability,
and mood swings over the past few months. Over the past few weeks, she
has increasingly felt warm and constantly uses the air conditioning in her
house despite other family members complaining of the cold. She has not
experienced chest pain, shortness of breath, dark stools or lightheadedness.
•Past medical history of two normal childbirths.
•Family history and social history are unremarkable.
•Review of systems notes occasional episodes of diarrhea and irregular
menstrual periods including some months during which she misses her
periods.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, thin, female; in no apparent distress.
Skin
Skin warm. No nodules or other lesions. Head shows focal areas of hair
loss.
HEENT/Neck
Normocephalic. Vision normal. Eyes show mild lid retraction, funduscopic
examination normal. Hearing normal. Ears, including pinnae, external
auditory canals, and tympanic membranes, normal. Nose and mouth
normal. Pharynx normal. Neck supple; thyroid mildly enlarged.
Heart/Cardiovascular
Tachycardia. S1 and S2 normal. No murmurs, rubs, gallops, or extra
sounds. Central and peripheral pulses normal. No jugular venous
distention. Blood pressure equal in both arms.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
exaggerated.
What is the suspected diagnosis, and what are the next steps in management?
236
II—CCS CASES BY CHIEF COMPLAINT
Case #97: Hyperthyroidism
Keys to Diagnosis
n
n
n
Look for a patient who presents with palpitations, diarrhea, weight loss despite increased
­appetite, or menstrual dysfunction. Other symptoms include tremor, anxiety, heat intolerance, sweating, and mood swings. Vital signs may show tachycardia.
Examination may show exophthalmos, goiter, tremor, or hyperreflexia.
Diagnosis is based on initial evaluation with TSH and free T4. Thyroid antibodies and
­radioactive iodide uptake (RAIU) help differentiate Graves’ disease from toxic multinodular
goiter. Rule out pregnancy in females.
Management
n
n
n
Propranolol for tachycardia and other beta-adrenergic symptoms. Methimazole is preferred
initial treatment. If the patient is pregnant, use propylthiouracil. Monitor every 1 to 2 months
until the patient is euthyroid.
Radioactive iodide is preferred for treating hyperthyroidism caused by toxic adenoma or
multinodular goiter except in pregnant women.
Surgical therapy if other therapies do not work or if obstructing goiter.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•ECG, 12-lead
•TSH, serum
•Free T4
•RAI uptake, thyroid (not in pregnant
women)
•hCG, beta, urine, qualitative (if female)
•Methimazole (or propylthiouracil if patient
is pregnant)
•Propranolol
•Thyroid autoantibodies
•Thyroid ultrasound
•CBC
•BMP
•LFT
•Advise patient, side effects of
medication
•Consult, endocrinology
•Counsel patient
•Reassure patient
•Follow up every 4 weeks with repeat TSH, free T4.
•Manage as outpatient, unless the patient shows signs of thyroid storm
(severe tachycardia, fever, mental status changes, pulmonary edema,
congestive heart failure).
•Diagnosis and therapy should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
ECG, TSH, Free T4, hCG
Advance clock to reschedule patient when all results are
reported.
RAI uptake, Thyroid autoantibodies, Thyroid ultrasound, CBC,
BMP, LFT
Advance clock to reschedule patient when all results are
reported.
Propranolol, Methimazole (or propylthiouracil or radioactive
iodide if appropriate), Counsel patient, Reassure patient,
Advise patient side effects of medication
Reschedule patient every 4 weeks for patient updates until
case end.
TSH, free T4 every 1-2 months
18—MISCELLANEOUS INTERNAL MEDICINE CASES
237
Case #98
Location: Emergency Department
Chief Complaint: Left-sided weakness
Case introduction
Initial vital signs
Initial history
•A 62-year-old white man arrives at the emergency department with a 2-hour
history of left-sided weakness that has resolved.
•Unremarkable
•The patient experienced left-sided weakness in his arms and legs 2 hours ago
while working at home. The weakness lasted for 30 minutes and then resolved.
He currently has no symptoms or complaints. He did not experience any chest
pain, shortness of breath or lightheadedness during the episode.
•Past medical history of hypertension and hyperlipidemia treated with hydrochlorothiazide and simvastatin.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses; left-sided carotid bruit present; thyroid
normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
238
II—CCS CASES BY CHIEF COMPLAINT
Case #98: Transient Ischemic Attack
Keys to Diagnosis
n
n
n
Look for an adult patient who presents with temporary unilateral symptoms that resolve,
such as monocular blindness, numbness, weakness, or temporary loss of consciousness.
Examination is generally unremarkable because symptoms typically resolve at presentation.
Diagnosis is based on ruling out other diagnoses and showing evidence embolic or atherothrombotic disease. Order head CT or MRI to rule out hemorrhage and brain lesion.
Order carotid Doppler and carotid angiogram to determine extent of stenosis if carotid bruit
­present.
Management
n
n
n
Admit to inpatient unit for workup owing to high risk of stroke within first 48 hours of TIA.
Aspirin ± dipyridamole. Treat hypertension, diabetes, hyperlipidemia, and smoking if present.
Carotid endarterectomy (CEA) if patient meets criteria. In general, CEA is recommended
in symptomatic patients with >50% stenosis per the North American Symptomatic Carotid
Endarterectomy Trial (NASCET).
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Neuro/Psych
•Head CT without contrast
•Carotid Doppler
•Carotid angiogram
•ECG, 12-lead
THERAPY
•Aspirin, therapy, oral
•Dipyridamole, oral
•CBC
•BMP
•PT/PTT
•Echocardiography
•Troponin
•Lipid profile
•Carotid endarterectomy (if
meets criteria)
•Consult, neurology
•Consult, vascular surgery
MONITORING
LOCATION
•Neuro checks every 2 hours.
•Admit patient to inpatient unit owing to high risk of stroke with first 48 hours of
TIA.
•Diagnosis and management should be instituted within 1 day of simulated time.
TIMING
SEQUENCING
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Head CT, Carotid Doppler, ECG, CBC, BMP, PT/PTT, Troponin, Lipid
profile, Neurochecks every 2 hours
Advance clock to results.
Change to inpatient unit.
Aspirin, Dipyridamole, Carotid angiography
Advance to results.
Carotid endarterectomy (if >50% stenosis), Consult neurology,
Consult vascular surgery
Advance to additional results and case end.
None
18—MISCELLANEOUS INTERNAL MEDICINE CASES
239
Case #99
Location: Inpatient unit
Chief Complaint: Decreased urine output
Case introduction
Initial vital signs
Initial history
•You are called by a nurse on the inpatient unit to see a 39-year-old Latino
man admitted 2 days ago for decreased urine output over the past 24 hours.
•Pulse: 108 beats/min
•The patient was admitted 2 days ago for repair of a right femoral neck fracture
after a motor vehicle accident. The operation and recovery has been uneventful up to this point. The nurse reports he has had 45 mL of urine output over
the past 24 hours in his foley catheter. The patient reports mild pain at the site
of surgery but no other complaints. His medications include gentamicin and
morphine.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Patient lying in bed, no acute distress.
Skin
Increased turgor. No nodules or other lesions. Hair and nails normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
Tachycardia. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Central and peripheral pulses normal. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Right hip with surgical dressing. 1+ pitting peripheral edema. Peripheral pulses
normal. No joint deformity or warmth. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
240
II—CCS CASES BY CHIEF COMPLAINT
Case #99: Acute Renal Failure Due to Acute
Tubular Necrosis
Keys to Diagnosis
n
n
n
Look for a patient who presents with anuria after trauma or new medication. Common
causes of renal failure include prerenal (hypovolemia, CHF, cirrhosis, sepsis), renal (myoglobinuria, IV ­contrast, or medications such as aminoglycosides, NSAIDs, ACE inhibitors,
and COX-2 inhibitors), or postrenal (BPH, stones). Vital signs may show tachycardia and
tachypnea.
On exam, look for peripheral edema, increased skin turgor and volume status changes.
Diagnosis is based on BMP (elevated creatinine, abnormal electrolytes), urinalysis (granular
casts in acute tubular necrosis), and urine osmolality (<400 in ATN and postrenal causes,
>500 in ­prerenal causes such as hypovolemia).
Management
n
n
n
If intrarenal cause of renal failure, such as ATN, stop all nephrotoxic medications. IV furosemide is commonly used, but there is little evidence to support its use. Dopamine is no longer
recommended. Hemodialysis if severe kidney injury (severe abnormalities in acid-base balance, electrolytes, volume overload or marked uremia).
If prerenal cause of renal failure, IV volume expansion with fluids. If postrenal, treat obstruction.
Monitor urine output.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: General, Skin, Extremities
•BMP
•CBC
•Urinalysis
•Urine osmolality
THERAPY
•Urine sodium
•Urine creatinine
•Creatinine clearance
•Phosphorus
•Magnesium
•ABG
•Hemodialysis (if severe injury)
TIMING
•Stop nephrotoxic medications
•Furosemide, IV
•Urine output
•Swan-Ganz catheter (if severe)
•Treat and monitor on the inpatient unit. Transfer to ICU if severe abnormalities
requiring hemodialysis.
•Diagnosis and therapy should be instituted within 6 hours of simulated time.
SEQUENCING
Exam
MONITORING
LOCATION
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities,
Neuro
CBC, BMP, Urinalysis, Urine osmolality, Urine sodium, Urine
creatinine, Creatinine clearance, Phosphorus, Magnesium
Advance to results of initial labs.
Stop any nephrotoxic meds, Furosemide, Urine output
Advance to additional results and patient updates.
Daily BMP, Urinalysis, Urine output, Urine osmolality
Advance to additional results, patient updates and case end.
None
18—MISCELLANEOUS INTERNAL MEDICINE CASES
241
Case #100
Location: Office
Chief Complaint: Palpitations
Case introduction
Initial vital signs
Initial history
•A 63-year-old white woman arrives at the office for a 1-week history of palpitations.
•Pulse: 130 beats/min, irregularly irregular
•The patient has been feeling frequent palpitations for the past week. She has
felt similar symptoms in less frequency for the past 3 months. The palpitations are associated with some dizziness, fatigue, and weakness but she has
not experienced any syncope or chest pain. She has not experienced any
diarrhea, constipation or shortness of breath. She underwent menopause at
age 51. She is sexually active with her husband only. She does not smoke
cigarettes or use alcohol.
•Past medical history includes 4 normal childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
Irregular heart rate. No murmurs, rubs, gallops, or extra sounds. Central
and peripheral pulses weak, irregular. No jugular venous distention. Blood
pressure equal in both arms.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses irregular. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory examinations
normal. Cerebellar function normal. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
242
II—CCS CASES BY CHIEF COMPLAINT
Case #100: Atrial Fibrillation
Keys to Diagnosis
n
n
n
Look for the presence of an irregular heart rate typically in the range of 110 to 140 beats/min.
Symptoms can include palpitations, fatigue, exercise intolerance, syncope, or ­dizziness, or the
patient may be asymptomatic.
On exam, look for presence of irregular heart rate and pulse as well as signs of ­hyperthyroidism,
heart failure, and valvular heart disease.
Diagnosis is based on ECG. If intermittent and not present on initial visit, order Holter
monitor. Additional studies should be ordered to look for an underlying cause (e.g., thyroid
dysfunction) and to determine if any heart failure is present.
Management
n
n
n
Treat any underlying causes, such as thyroid dysfunction if present. The cornerstone of management is rate control and anticoagulation.
For rate control: If hemodynamically stable, cardiology consult and initial management
with a calcium channel blocker (verapamil) or beta-blocker (atenolol). If hemodynamically
unstable, admit to emergency department and consider cardioversion with sedation (e.g.,
midazolam) if transesophageal echocardiography shows no thrombus and anticoagulation
started.
For anticoagulation, use warfarin or if warfarin contraindicated, use aspirin and clopidogrel.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Chest, Heart, Extremities
•ECG, 12-lead
•Echocardiography
THERAPY
•TSH, serum
•Free T4
•BMP
•CBC
•PT/PTT
•BNP
•Chest X-ray, PA/lateral
•Advise patient, side effects of
medication
•Warfarin, oral
•Consult, cardiology
•Rate control drug (calcium channel
blocker or beta blocker)
•Holter monitor if intermittent irregular heart beat.
•If stable, manage as outpatient.
•Admit to emergency department if hemodynamically unstable or attempting
cardioversion.
•Diagnosis and therapy should be instituted within 2 days of simulated time if
patient stable.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Exam
Orders
Clock
End Orders
General, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
ECG, 12-lead
Advance to ECG results.
Echocardiography, TSH, Free T4, CBC, PT/PTT, BMP, BNP,
Troponin, Chest X-ray
Reschedule patient for follow-up appointment after results.
Consult cardiology, Verapamil (or other rate control drug), Warfarin
Reschedule patient for follow-up visit in 1 week.
Heart
ECG, PT/PTT.
Advance to additional results, patient updates and case end.
None
18—MISCELLANEOUS INTERNAL MEDICINE CASES
243
Case #101
Location: Emergency Department
Chief Complaint: Fever
Case introduction
Initial vital signs
Initial history
•A 44-year-old white woman arrives at emergency department for a 1-day
history of fever and night sweats.
•Temperature: 39.8 degrees C (103.6 degrees F)
•The patient has a history of acute myeloid leukemia and completed her third
cycle of chemotherapy 3 days ago. She had night sweats last night and has
felt shaking chills throughout the day. She has not experienced cough, shortness of breath, chest pain, diarrhea or dysuria.
•Past medical history of two normal childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Thin, female; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair loss from chemotherapy.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
244
II—CCS CASES BY CHIEF COMPLAINT
Case #101: Neutropenic Fever
Keys to Diagnosis
n
n
n
Look for a patient with a history of chemotherapy or other immunodeficiency who presents
with fever, night sweats, or shaking chills. Vital signs show increased temperature.
On exam, look for potential sources of infection. Often, the exam findings are unremarkable.
Diagnosis is based on presence of fever and low absolute neutrophil count on CBC. Lab
studies should focus on identifying sepsis (Lactate) and cultures/imaging to look for a source
of infection.
Management
n
n
n
Empiric antibiotic therapy—multiple options (e.g., cefepime). If beta-lactam allergy, ­consider
alternative, such as levofloxacin + tobramycin. Adding an aminoglycoside (e.g., gentamicin)
and an antifungal (e.g., amphotericin B) may be considered in some patients.
Admit to inpatient unit with reverse isolation.
Monitor CBC, temperature, and vital signs.
245
18—MISCELLANEOUS INTERNAL MEDICINE CASES
Case #101: Neutropenic Fever—cont’d
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•CBC
•BMP
•Urinalysis
•LFT
•Blood culture
•Sputum C&S
•Urine culture
•Stool culture
•Chest X-ray, PA/lateral
•CT, chest and abdomen
•Lactate, serum
•Antibiotic therapy (e.g., cefepime)
•Consult, infectious disease
•Reverse isolation
•CBC, daily
•Vital signs
•Admit to inpatient unit for IV empiric antibiotics and initial management.
•Diagnosis and management should be instituted within 24 hours of simulated
time.
Exam
Orders
Clock
Orders
Location
Clock
Orders
Clock
End Orders
Complete
CBC, BMP, LFT, Lactate, Urinalysis, Urine culture, Blood culture,
Stool culture, Chest X-ray PA/lateral
Advance to results of CBC.
Cefepime (or other empiric antibiotic) Reverse isolation, Consult
infectious disease, CT chest and abdomen
Change to inpatient unit.
Advance to additional patient updates.
CBC and vital signs daily
Advance to additional results and case end.
None
C H A P T E R
19
Vaginal Bleeding
Key Orders*
Order
CCS Terminology
Pregnancy test, urine, qualitative
hCG, beta, urine, qualitative
HIV antibody test, rapid, blood
CBC with differential
Antibody, rapid HIV test, blood
CBC with differential
PT/PTT
PT/PTT
Bleeding time
Factor VIII, plasma
Ristocetin cofactor
HIV test, ELISA, serum
Cervical DNA probe test, human
papillomavirus
Pap smear
Platelet antibody, plasma
CA-125, serum
Endocervical curettage
Bleeding time
Antihemophilic factor, plasma
Platelet aggregation
Antibody, HIV, ELISA, serum
Human papillomavirus, DNA probe
test, cervix
Papanicolaou smear
Antibody, platelet, plasma
CA-125, serum
Curettage, endocervical
Colposcopy
LEEP, uterine cervix
Cervical biopsy
Cervical biopsy, cone
Cervical biopsy, laser cone
Endometrial biopsy
Colposcopy
Loop electrocautery excision
Biopsy, cervix uteri
Biopsy, cervix, cone
Biopsy, cervix, laser cone
Biopsy, endometrium
Cervical DNA probe test, chlamydia
Chlamydia trachomatis DNA probe
test, cervix
Neisseria gonorrhoeae DNA probe
test, cervix
Antigen, von Willebrand factor,
plasma
Cervical DNA probe test, gonorrhea
Von Willebrand factor antigen
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
Office Setting
5 min (stat),
20 min (routine)
20 min
1 hr (stat),
24 hr (routine)
1 hr (stat),
24 hr (routine)
1 hr
2 hr
6 hr
24 hr
24 hr
24 hr
24 hr
24 hr
5 min (to perform),
24 hr (for results)
24 hr
24 hr
24 hr
24 hr
24 hr
1 hr (to perform),
24 hr (for results)
3 days
3 days
7 days
247
19—VAGINAL BLEEDING
Case #102
Location: Office
Chief Complaint: Vaginal bleeding with irregular periods
Case introduction
Initial vital signs
Initial history
•A 14-year-old Latina girl arrives at the office with her mother for a 5-day history of vaginal bleeding.
•Unremarkable
•The patient has had excessive vaginal bleeding over the past 5 days related
to her period. She uses 10 to 12 pads a day. She began menarche at age
13 years and has had irregular menstrual cycles since. Her menstrual cycle
lasts from 15 to 45 days, and she often has bleeding several days throughout
her cycle. Her periods are very heavy and last from 5 to 10 days. She is not
sexually active. She does not smoke cigarettes or drink alcohol.
•No past medical history of a bleeding disorder.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal labia. Vagina with blood and clots. No cervical lesions. Uterus not
enlarged. No adnexal masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
248
II—CCS CASES BY CHIEF COMPLAINT
Case #102: Dysfunctional Uterine Bleeding
Keys to Diagnosis
n
n
n
ook for a teenage girl or perimenopausal woman who presents with excessive vaginal
L
­bleeding. History will reveal irregular periods, excessive bleeding during periods, bleeding
in between periods, and periods lasting for numerous days. Typically, no family history of a
bleeding disorder.
Examination is unremarkable and shows absence of any masses or lesions.
DUB is a diagnosis of exclusion; therefore, exclude other pathology such as thyroid dysfunction; polycystic ovary disease; bleeding disorder; and lesions of the uterus, endometrium, or
cervix. Be sure to order a pregnancy test and evaluate for anemia.
Management
n
n
n
n
I f mild to moderate bleeding: Estrogen therapy (e.g., medroxyprogesterone acetate oral for
10 days) plus iron therapy for ­anemia. Consider estrogen/progestin oral contraceptive pill
­after estrogen therapy completed. If patient wants to become pregnant, use clomiphene
­citrate instead.
If severe bleeding with hypotension or severe anemia: change to inpatient unit, use conjugated
estrogen (Premarin) IV or consider dilation and curettage (D&C) and blood transfusion.
For postmenopausal patients, consider endometrial ablation.
Treat anemia with iron replacement.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•CBC
•PT/PTT
•hCG, urine, qualitative
•TSH
THERAPY
•Estrogen therapy (medroxyprogesterone
or Premarin if severe bleeding)
•Iron sulfate
•Orthostatic vitals
•Ferritin
•Iron and TIBC
•Transvaginal ultrasound
•Endometrial biopsy
(if age >35 years)
•Diet, high iron
•Counsel patient
•Reassure patient
•Advise patient, side effects of
medication
•Naproxen (for pain)
MONITORING
LOCATION
•None
•For mild to moderate bleeding, manage as an outpatient.
•Admit to inpatient unit if severe bleeding requiring dilation and curettage (D&C)
or severe anemia requiring blood transfusion.
•Diagnosis and management should be instituted within the 2 days of
simulated time.
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Skin, HEENT, Heart, Lungs, Abdomen, Genitalia, Rectal
± Complete
Orthostatic vitals, hCG beta urine qualitative, CBC, PT/PTT
Advance clock to results of initial lab tests.
Ferritin, Iron serum w/TIBC, TSH, Transvaginal ultrasound
Reschedule patient after results are reported.
Estrogen therapy (medroxyprogesterone), Naproxen, Iron sulfate,
Diet high iron, Counsel patient, Reassure patient, Advise patient
side effects of medication
Advance clock for additional updates and case end.
None
19—VAGINAL BLEEDING
249
Case #103
Location: Office
Chief Complaint: Vaginal bleeding with regular periods
Case introduction
Initial vital signs
Initial history
•A 15-year-old white girl arrives at the office with her mother for a 6-day history
of excessive vaginal bleeding during her period.
•Unremarkable
•The patient has had excessive vaginal bleeding over the past 6 days related to
her period, with the heaviest bleeding in the past 2 days. She uses 12 pads a
day. She began menarche at age 12 years and normally has regular menstrual
cycles of 28 days with 3 to 4 days of bleeding during her period. She has
occasionally had heavy periods in the past but normally does not have
­bleeding outside her period. She used to get heavy nosebleeds as a child.
She is not sexually active. She does not smoke cigarettes or drink alcohol.
•Past medical history is unremarkable.
•Family history includes a father with heavy nosebleeds as a child and excessive bleeding after dental procedures.
•Social history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal labia. Vagina with blood and clots. No cervical lesions. Uterus not
enlarged. No adnexal masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
250
II—CCS CASES BY CHIEF COMPLAINT
Case #103: Von Willebrand Disease
Keys to Diagnosis
n
n
n
Look for a young girl with increased bleeding during periods. Unlike dysfunctional uterine
bleeding, the menstrual cycle will be regular. Another common presentation in either a boy
or girl is excessive nosebleeds or bleeding after a dental procedure. There is often a family
history of bleeding in a parent because most common types of von Willebrand disease are
autosomal dominant.
Examination is generally unremarkable.
P T/PTT may show a prolonged PTT. Von Willebrand factor antigen and factor VIII are decreased. Bleeding time is no longer routinely performed, but it would be elevated. Ristocetin
cofactor (Platelet aggregation) shows abnormal aggregation to ristocetin. Also evaluate CBC
and iron studies for iron deficiency anemia.
Management
n
n
n
Avoid aspirin and NSAIDs (cancel these medicines if the patient is on them).
Combined oral contraceptives are the treatment of choice for vaginal bleeding in vWD.
If the patient is trying to get pregnant, consider desmopressin acetate (DDAVP), or
­Aminocaproic acid.
Correct anemia with diet, iron replacement.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•CBC
•PT/PTT
•Ristocetan Cofactor
•Von Willebrand factor (vWF) antigen plasma
•Factor VIII plasma
THERAPY
•Bleeding time
•Orthostatic vitals
•hCG, beta, urine, qualitative
•TSH, serum
•Ferritin
•Iron & TIBC
•Counsel patient
•Reassure patient
•Advise patient, no NSAIDs
•Advise patient, no aspirin
•Medications (oral contraceptive or DDAVP
or aminocaproic acid)
•Iron sulfate
•Diet, high iron
•None
•Office
•Admit if need for transfusion
•Management should be instituted within 2 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Complete
Orthostatic vitals, hCG, CBC, PT/PTT
Advance clock to results of PT/PTT.
Factor VIII plasma, Ristocetan cofactor, von Willebrand factor
antigen plasma, Ferritin, Iron & TIBC, TSH
Advance clock to reschedule patient after all results reported.
Medications (Oral contraceptive or others), Advise patient side
effects of medication, Counsel patient, Reassure patient,
Advise patient no NSAIDs, Advise patient no aspirin, Iron
sulfate, Diet high iron
Advance to patient updates and case end.
None
19—VAGINAL BLEEDING
251
Case #104
Location: Office
Chief Complaint: Vaginal bleeding after intercourse
Case introduction
Initial vital signs
Initial history
•A 33-year-old African American woman arrives at the office for a 1-month history of vaginal bleeding after intercourse.
•Unremarkable
•The patient has a 1-month history of vaginal bleeding after intercourse. She
has had mild bleeding over the past 2 days associated with abdominal pain.
She has not had vaginal discharge, fevers, or chills. She currently has sexual
relationships with three men and occasionally uses barrier contraception. She
smokes one-half pack of cigarettes a day and drinks six to eight alcoholic
drinks on weekends.
•Past medical history includes treatment for chlamydia infection 2 years ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. No adnexal
masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
252
II—CCS CASES BY CHIEF COMPLAINT
Case #104: Cervical Cancer
Keys to Diagnosis
n
n
n
Look for an adult woman with bleeding after intercourse. History often shows several risk
factors, such as smoking, early age of first intercourse, multiple sexual partners, lack of barrier
protection, and treatment for prior sexually transmitted infections.
Examination may or may not reveal any cervical lesions.
Order Pap smear and HPV testing as initial studies followed by colposcopy for diagnosis.
Management
n
n
n
For stage 1A—cone biopsy (LEEP) or simple hysterectomy. For advanced stage, radical hysterectomy, radiation therapy, and/or chemotherapy may be needed.
Staging including abdominal and chest CT.
Counsel patient, cancer diagnosis.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Genitalia, Abdomen
•Exam: Additional
•Pap smear
•HIV, serum, ELISA
•HPV DNA probe test, cervix
•hCG, urine, qualitative
•Colposcopy (automatic Ob-Gyn
•Hepatitis B surface antigen
consult)
•Gonococcal DNA probe test, cervix
•Cervical biopsy
•Chlamydia DNA probe test, cervix
•Endocervical curettage
•LEEP (or cone)
•Reassure patient
•Advise patient, no smoking
•Counsel patient
•Advise patient, cancer diagnosis
•Consult, hematology/oncology
•Pap smear 4–6 months after treatment.
•Office
•Diagnosis and management should be instituted within 4 days of simulated
time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Genitalia + Additional
Pap smear, HPV DNA, hCG, HIV, Hepatitis B surface antigen,
Gonorrhea, Chlamydia, Advise patient no smoking
Advance clock to reschedule patient when all results are reported.
Colposcopy (consult Ob-Gyn), Cervical biopsy, endocervical
curretage
Advance to colposcopy results.
LEEP, Reassure patient, Counsel patient, Advise patient cancer
diagnosis, Consult hematology/oncology
Advance to additional results, patient updates and case end.
None
19—VAGINAL BLEEDING
253
Case #105
Location: Office
Chief Complaint: Postmenopausal vaginal bleeding
Case introduction
Initial vital signs
Initial history
•A 62-year-old white woman arrives at the office for a 3-day history of vaginal
bleeding.
•Height: 160.3 cm (63.1 in)
•Weight: 91.2 kg (201.1 lb)
•Body mass index: 35.5 kg/m2
•The patient has had intermittent vaginal bleeding for the past 4 months with
heavier bleeding over the past 3 days. She has experienced 2-3 days of bleeding occurring at irregular intervals on a weekly basis. The bleeding was initially
very light and has progressed with more significant bleeding over the last two
weeks. She has not experienced any lightheadedness, dizziness or syncope.
She is a widower and has not been sexually active for the past two years.
•Past medical history shows no family history of a bleeding disorder. She underwent menopause at age 55. She has a history of breast cancer 6 years ago
treated with Tamoxifen, now in remission.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, overweight female; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. No adnexal
masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
What is the suspected diagnosis, and what are the next steps in management?
254
II—CCS CASES BY CHIEF COMPLAINT
Case #105: Endometrial Cancer
Keys to Diagnosis
n
n
n
Look for a patient who presents with postmenopausal bleeding. Risk factors include obesity,
diabetes, nulliparity, early menarche, late menopause, tamoxifen and estrogen therapy.
Examination is generally unremarkable.
Endometrial biopsy is recommended in women older than 35 years with vaginal bleeding.
CA-125 tumor marker. Evaluate for anemia.
Management
n
n
n
Surgery is the mainstay of treatment. Consult radiation therapy and oncology.
Staging with abdominal CT (or pelvic ultrasound), chest CT.
Treat anemia with iron replacement.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Endometrial biopsy (Consult, Ob-Gyn)
•CA-125 serum
•CBC
THERAPY
•LFT
•Pap smear
•Abdominal CT
•Chest CT
•Ferritin
•Iron & TIBC
•Reassure patient
•Hysterectomy, laparoscopic
•Advise patient, cancer diagnosis
•Consult, hematology/oncology
•Pelvic examination every 3 months for 2 years.
•Patients can generally be managed as outpatients.
•Management should be instituted within 4 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
General, Skin, Abdomen, Genitalia, Rectal ± Complete
CBC, Pap smear, Endometrial biopsy (Consult, Ob-Gyn)
Advance clock to reschedule patient when all results are reported.
LFT, CA-125 serum, Chest CT, Abdominal CT, Hysterectomy,
Advise patient cancer diagnosis, Reassure patient, Consult
hematology/oncology
Advance to results of additional results and case end.
None
19—VAGINAL BLEEDING
255
Vaginal Bleeding—Key Points
n
n
aginal bleeding may represent gynecologic pathology or an underlying bleeding disorder.
V
Important orders to keep in mind include:
n CBC
n P T/PTT
n Pap smear
n HPV DNA, cervix
n hCG, beta, urine, qualitative
n Endometrial biopsy (if age >35 years)
n Transvaginal ultrasound
C H A P T E R
20
Vaginal Discharge
Key Orders*
Order
CCS Terminology
Vaginal pH
Vaginal secretions, mount
Vaginal KOH prep
Pregnancy test, urine, qualitative
pH, vaginal secretions
Wet mount, vaginal secretions
KOH prep, vaginal secretions
hCG, beta, urine, qualitative
HIV antibody test, rapid, blood
Vaginal Gram stain
Urinalysis
Antibody, rapid HIV test, blood
Gram stain, vaginal secretions
Urinalysis
HIV test, ELISA, serum
Vaginal culture
Pap smear
Cervical GC culture
Cervical DNA probe test, human
papillomavirus
Vaginal Tzanck test
Cervical chlamydia culture
Cervical DNA probe test,
chlamydia
Cervical DNA probe test,
gonorrhea
Vaginal fungal culture
Vaginal viral culture
Counseling, no intercourse
Counseling, side effects of
medication
Counseling, birth control
Counseling, no alcohol
Counseling, safe sex techniques
Counseling, sexual partner need
treatment
Reassure patient
Counseling, no tight-fitting
garments
Antibody, HIV, ELISA, serum
Bacterial culture, vagina
Papanicolaou smear
Gonococcal culture, cervix
Human papillomavirus, DNA probe
test, cervix
Tzanck test, vagina
Chlamydia culture, cervix
Chlamydia trachomatis DNA probe
test, cervix
Neisseria gonorrhoeae DNA probe
test, cervix
Fungal culture, vagina
Viral culture, vagina
Advise patient, no intercourse
Advise patient, side effects of
medication
Advise patient, contraception
Advise patient, no alcohol
Advise patient, safe sex techniques
Advise patient, sexual partner needs
treatment
Reassure patient
Advise patient, no tight-fitting
garments
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
Office Setting
5 min
5 min
5 min
5 min (stat),
20 min (routine)
20 min
20 min
30 min (stat),
6 hr (routine)
24 hr
24 hr
24 hr
24 hr
24 hr
2 days
3 days
3 days
3 days
4 days
7 days
5 min
5 min
5 min
5 min
5 min
5 min
5 min
5 min
20—VAGINAL DISCHARGE
257
Case #106
Location: Office
Chief Complaint: Foul-smelling vaginal discharge
Case introduction
Initial vital signs
Initial history
•A 31-year-old white woman arrives at the office for a 1-week history of foul
smelling vaginal discharge and itching.
•Unremarkable
•The vaginal discharge is malodorous, gray, frothy and worsens after intercourse. She has mild vaginal itching. There is no pain with intercourse or pain
with urination. She is sexually active with three male partners and uses an
intrauterine device and occasionally condoms for contraception. She has not
experienced shaking chills, abdominal pain, fever or chills.
•Past medical history includes treatment for chlamydia two years ago.
•Family history, social history and review of systems is unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia,
Rectal
Initial Results: Time Course: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
Abdomen
Bowel sounds normal. No masses or tenderness.
Genitalia
Vulvar excoriations. Thin, gray malodorous vaginal discharge. Normal cervix.
Uterus not enlarged. No adnexal masses or tenderness.
ADDITIONAL MANAGEMENT
Orders
•Vaginal pH, wet mount, KOH prep, hCG urine qualitative, HIV test rapid,
Vaginal Gram stain
Results: Time Course: Advance clock 20 minutes to results of tests
Results (Pertinent Findings)
Vaginal pH
5.8 pH unit (nl = 3.5–4.5)
Wet mount
Numerous clue cells observed. No trichomonads seen.
KOH prep
Strong odor present. No hyphae or pseudohyphae.
hCG, urine
Negative
HIV, rapid test
Negative
Vaginal Gram stain
Numerous small gram-positive and gram-negative rods.
What is the suspected diagnosis, and what are the next steps in management?
258
II—CCS CASES BY CHIEF COMPLAINT
Case #106: Bacterial Vaginosis
Keys to Diagnosis
n
n
n
ypical symptoms include a fishy vaginal odor (particularly after intercourse); vulvar itching;
T
and thin, gray vaginal discharge. Risk factors include recent antibiotic use, IUD use, and
increased numbers of sexual partners or new sexual partner.
Exam shows thin, gray discharge with normal uterus size and no adnexal masses.
Diagnosis is confirmed with rapid vaginal tests. Vaginal wet mount shows clue cells, vaginal
pH >4.5, vaginal gram stain may show Gardnerella morphotypes (small, gram-variable rods).
KOH prep shows absence of hyphae and wet mount shows absence of trichomonads. Pregnancy test should be performed. Consider tests for sexually transmitted disease as indicated.
Management
n
n
etronidazole is the treatment of choice for 7 days. Avoid alcohol (disulfiram-like reaction)
M
and intercourse during therapy.
Treatment of partners generally not needed.
DIAGNOSIS
THERAPY
OPTIMAL ORDERS
ADDITIONAL ORDERS
•Exam: Genitalia (Complete)
•Vaginal pH
•Vaginal secretion, wet mount
•Vaginal KOH prep
•hCG, beta, urine, qualitative
•Metronidazole, oral, continuous
•Advise patient, no alcohol
•Advise patient, no intercourse
•Vaginal Gram stain
•HIV antibody test, rapid, blood
•Cervical GC culture
•Cervical culture, chlamydia
•Pap smear
•Advise patient, side effects of
medication
•Advise patient, birth control
•Advise patient, safe sex
techniques
•Reassure patient
MONITORING
LOCATION
TIMING
•Not important for this case.
•Outpatient management is appropriate.
•After physical exam, be sure to order the rapid 5-minute tests (pH, wet mount,
KOH, hCG)
•Management should be instituted within 2 hours of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Complete
Vaginal pH, Vaginal wet mount, Vaginal KOH prep, hCG urine; also
consider Vaginal Gram stain, HIV test rapid, Cervical GC culture,
Cervical chlamydia culture, Pap smear if case indicates.
Advance clock to results of initial tests (20 minutes).
Metronidazole, Advise patient (no alcohol, no intercourse, birth
control, safe sex, side effects of medications), Reassure patient
Advance clock to additional patient feedback and case end.
Cancel medication after 7 days.
None
20—VAGINAL DISCHARGE
259
Case #107
Location: Office
Chief Complaint: Vaginal discharge and pain during intercourse
Case introduction
Initial vital signs
Initial history
•A 34-year-old Latina woman presents to the office with vaginal discharge and
pain during intercourse for 4 days.
•Unremarkable
•The vaginal discharge has been progressively worsening over the past 4
days and is thick, white, and curdlike. She has pain during intercourse and
sometimes pain with urination. She notes intense vaginal itching and burning
over the past two days. She had a dental infection 3 weeks ago and recently
finished a course of clindamycin therapy. She is married, monogamous with
her husband only and uses condoms for contraception.
•She does not smoke, drink alcohol, or use illicit drugs.
•Family history, social history and review of systems is unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Time Course: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
Abdomen
Bowel sounds normal. No abdominal tenderness or masses.
Genitalia
Vulvar and vaginal edema and erythema. Thick, white vaginal discharge. Cervix
normal. Uterus not enlarged. No adnexal masses.
ADDITIONAL MANAGEMENT
Orders
•Vaginal pH, wet mount, KOH prep, hCG urine qualitative, Urinalysis
Results: Time Course: Advance clock to results of tests
Results (Pertinent Findings)
Vaginal pH
4.0 pH unit (nl = 3.5–4.5)
Wet mount
Hyphae present. No trichomonads identified.
KOH prep
Hyphae and budding yeasts present.
hCG, urine
Negative
What is the suspected diagnosis, and what are the next steps in management?
260
II—CCS CASES BY CHIEF COMPLAINT
Case #107: Candida Vulvovaginitis
Keys to Diagnosis
n
n
n
Typical symptoms include vaginal burning and itching, pain after intercourse, or pain with
urination. Look for thick, white, curdlike “cottage cheese” vaginal discharge. Patients may
have history of immunosuppression (especially diabetes) or antibiotic use, but not necessarily
a history of multiple partners or unprotected sex.
Vaginal exam may show edema, beefy red mucosa, and thick white discharge.
Diagnosis can be made by exam, wet mount, or KOH prep. Pregnancy test should be
­performed.
Management
n
n
n
Topical azoles (miconazole or butoconazole) show better cure rates than nystatin. Treatment
is typically 7 days.
Counsel patients to wear loose-fitting underwear to reduce the warm, moist environment
that promotes Candida growth. Treatment of partners is generally not necessary.
If history of recurrent candida infections or if other infections present, evaluate for immunosuppression, such as diabetes or HIV.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Genitalia (Complete)
•Urinalysis
•Vaginal pH
•Pap smear
•Vaginal secretion, wet mount
•Vaginal KOH prep
•hCG, beta, urine, qualitative
•Miconazole nitrate, vaginal, continuous
•Advise patient, side effects of
•Advise patient, no tight-fitting garments
medication
•Advise patient, no intercourse
•Reassure patient
•Not important for this case.
•Outpatient management is generally appropriate.
•Management should be instituted within 1 day of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
Abdomen, genitalia +/- Others
Vaginal pH, Vaginal wet mount, Vaginal KOH prep, hCG urine; also
consider Urinalysis, and Pap smear
Advance clock to results of initial tests (20 minutes).
Miconazole nitrate, Advise patient (no tight-fitting garments, no
intercourse, side effects of medication), Reassure patient
Advance clock to patient updates and case end. Cancel
medication after 7 days.
None
20—VAGINAL DISCHARGE
261
Case #108
Location: Office
Chief Complaint: Vaginal discharge and painful urination
Case introduction
Initial vital signs
Initial history
•A 26-year-old African American woman presents to the office with vaginal
discharge and painful urination for 2 days.
•Unremarkable
•The patient describes vaginal discharge that has been worsening over the past
2 days and is malodorous and green-yellow. Over the past day, she notes pain
on urination and mild lower abdominal tenderness. She has had one episode of
pain during intercourse. She is sexually active with two male partners and uses
the oral contraceptive pill and occasionally uses condoms.
•Past medical history includes treatment for gonorrhea three years ago.
•Family history, social history and review of systems is unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Time Course: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
Abdomen
Bowel sounds normal. Mild lower abdominal tenderness.
Genitalia
Vulvar excoriations; frothy, green-yellow vaginal discharge. Cervix with bright erythema.
Uterus not enlarged. No adnexal masses or cervical motion tenderness.
ADDITIONAL MANAGEMENT
Orders
•Vaginal pH, wet mount, KOH prep, hCG urine qualitative, HIV test rapid, Cervical
DNA chlamydia, Cervical DNA gonorrhea, Urinalysis
Results: Time Course: Advance clock to results of tests
Results (Pertinent Findings)
Vaginal pH
5.5 pH unit (nl = 3.5–4.5)
Wet mount
Motile Trichomonad organisms identified.
KOH prep
No hyphae or pseudohyphae.
hCG, urine
Negative
HIV, rapid test
Negative
What is the suspected diagnosis, and what are the next steps in management?
262
II—CCS CASES BY CHIEF COMPLAINT
Case #108: Trichomoniasis
Keys to Diagnosis
n
n
n
Patients typically present with vaginal itching and frothy, yellow-green, malodorous vaginal
discharge; pain during intercourse; or pain during urination. Because trichomoniasis is a
sexually transmitted infection, there usually is a history of multiple partners or unprotected
sex.
Examination may show vulvar erythema, vaginal discharge, “strawberry” cervix, or lower
abdominal tenderness.
Vaginal wet mount is the diagnostic test of choice to view motile organisms. pH is typically
>4.5 but not specific. Vaginal culture is sensitive and specific but takes more time.
Management
n
n
Metronidazole for 7 days is the treatment of choice. Counseling to avoid alcohol and sex
during treatment is recommended.
Treatment of sexual partners is also recommended to avoid reinfection.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Genitalia, Abdomen
•Urinalysis
•Vaginal pH
•HIV antibody test, rapid, blood
•Vaginal secretion, wet mount
•Cervical DNA, gonorrhea
•Vaginal KOH prep
•Cervical DNA, chlamydia
•hCG, beta, urine, qualitative
•Pap smear
•Metronidazole, oral, continuous
•Advise patient, side effects of
•Advise patient, no alcohol
medication
•Advise patient, no intercourse
•Advise patient, birth control
•Advise patient, sexual partner need
•Advise patient, safe sex techniques
treatment
•Reassure patient
•Not important for this case.
•Outpatient management is appropriate.
•Management should be instituted within 1 day of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
Complete
Vaginal pH, Vaginal wet mount, Vaginal KOH prep, hCG urine,
Urinalysis; also consider HIV test rapid, Cervical DNA chlamydia,
Cervical DNA gonorrhea, Pap smear
Advance clock to results of initial tests (20 minutes).
Metronidazole, Advise patient (partner needs treatment, no alcohol,
no intercourse, birth control, safe sex, side effects of medication)
Reassure patient
Advance clock to additional patient feedback and case end. Cancel
medication after 7 days.
None
263
20—VAGINAL DISCHARGE
Vaginal Discharge—Key Points
n
n
n
n
n
n
enerally, these patients present in the office with stable vital signs, so begin management
G
with a physical exam.
For most patients, order the rapid 5-minute tests (vaginal pH, wet mount, KOH prep,
hCG; Table 20-1). Vaginal Gram stain is optional but can be helpful in the diagnosis of
bacterial vaginosis.
For patients who have had multiple partners or unprotected sex, consider adding tests for
HIV, hepatitis, gonorrhea, and chlamydia.
For patients who have not had a recent evaluation and meet criteria, consider ordering a Pap
smear and/or HPV testing.
If a patient has a positive hCG test result and is pregnant, the treatments remain the same
but include additional pregnancy management (see Case #109).
If a patient has recurrent Candida infections or signs of infection in other areas, order a
follow-up HIV test if the rapid test result is negative and order a fasting glucose for diabetes
mellitus. (See case #59 and Case #25.) If HIV positive, manage Candida infection with oral
fluconazole.
TABLE 20-1 n Summary of Causes of Vaginal Discharge
Bacterial Vaginosis
Symptoms
History
Vaginal discharge
Physical exam
pH
Wet mount
KOH prep
Treatment
Counseling
Candida Vulvovaginitis
Fishy vaginal odor
Vaginal burning and itching,
(particularly after
pain after intercourse, or
intercourse), vulvar itching pain with urination
less common
Risk factors include recent Patients may have history
antibiotic use, IUD use,
of immunosuppression
increased numbers of
or antibiotic use but not
sexual partners, or new
necessarily a history of
sexual partner
multiple partners or
unprotected sex
Thin, gray or white
Thick, white, curdlike
“cottage cheese”
Thin, gray discharge
Erythema and edema of
adherent to vaginal walls
the vulva and vagina,
beefy red mucosa with
white plaques, cervix
often normal
>4.5
<4.5
Clue cells (epithelial cells
May be normal or show
covered with bacteria)
hyphae and budding
yeast forms
Fishy odor, positive whiff
Hyphae and yeast present
test result
Metronidazole, oral,
Miconazole nitrate, vaginal,
continuous for 7 days
continuous for 7 days
Avoid alcohol, avoid sex
Advise no tight-fitting
garments
Trichomoniasis
Vaginal itching, pain after
intercourse, or pain
with urination
History of multiple
partners and
unprotected sex
Frothy, yellow-green,
malodorous
Vulvar erythema,
“strawberry” cervix,
lower abdominal
tenderness
>4.5
Motile organisms with
large numbers of white
cells
Normal or may show
positive whiff test
Metronidazole, oral,
continuous for 7 days
Treat partners, avoid
alcohol, avoid sex
C H A P T E R
21
Miscellaneous
Obstetrics/Gynecology Cases
Key Orders*
Order
CCS Terminology
Pregnancy test, urine, qualitative
hCG, beta, urine, qualitative
HIV antibody test, rapid, blood
Urine Gram stain
Antibody, rapid HIV test, blood
Gram stain, urine, unspun
Urinalysis
Urinalysis
Breast ultrasound
US, breast
CBC with differential
CBC with differential
Type and screen, blood
Type and screen, blood
Cortisol, plasma
Transvaginal ultrasound
Pelvic ultrasound, transabdominal
Mammography
Hepatitis B surface antigen
RPR, serum
Rubella serology
Urine culture
Pap smear
Vulvar biopsy
Breast biopsy
Breast, fine-needle aspirate
TSH, serum
Prolactin, serum
FSH, serum
Cervical DNA probe test, chlamydia
Cortisol, plasma
US, pelvis, transvaginal
US, pelvis, transabdominal
Mammography
Antigen, hepatitis B, surface, serum
Rapid plasma regain test, serum
Serology, rubella
Bacterial culture, urine
Papanicolaou smear
Biopsy, vulva
Biopsy, breast, needle
Aspirate, breast, fine-needle
Hormone, thyroid-stimulating, serum
Prolactin, serum
Hormone, follicle-stimulating, serum
Chlamydia trachomatis DNA probe
test, cervix
Neisseria gonorrhoeae DNA probe
test, cervix
Antibody, varicella-zoster virus, IgG,
serum
Dehydroepiandrosterone, serum
Testosterone, serum
Hormone, luteinizing, serum
Cervical DNA probe test, gonorrhea
Varicella-zoster virus, IgG antibody,
serum
DHEA-S
Testosterone, serum
LH, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
Office Setting
5 min (stat),
20 min (routine)
20 min
20 min (stat),
1 hr (routine)
30 min (stat),
6 hr (routine)
30 min (stat),
4 hr (routine)
1 hr (stat),
4 hr (stat)
1 hr (stat),
4 hr (routine)
1 hr
4 hr
4 hr
5 hr
8 hr
10 hr
24 hr
24 hr
24 hr
25 hr
25 hr
24 hr 15 min
2 days
3 days
3 days
3 days
3 days
3 days
6 days
7 days
8 days
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
265
Case #109
Location: Office
Chief Complaint: Dysuria
Case introduction
Initial vital signs
Initial history
•A 24-year-old American Indian woman arrives at the office for a 2-day history
of worsening dysuria.
•Temperature: 38.0 degrees C (100.5 degrees F)
•The patient complains of worsening pain on urination for the past 2 days. She
has also experienced urinary frequency and urgency. She has not noticed any
blood in her urine and does not complain of any vaginal discharge. There is no
history of night sweats or shaking chills. She is sexually active with her husband only. Her last menstrual period was 5 weeks ago. She does not smoke,
drink alcoholic beverages, or use illegal drugs.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Genitalia, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Breasts
Nipples normal. Breasts mildly enlarged and tender.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen not
palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus mildly enlarged. No adnexal
masses or tenderness.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
266
II—CCS CASES BY CHIEF COMPLAINT
Case #109: Urinary Tract Infection/Pregnancy
Keys to Diagnosis
n
n
n
Typical symptoms of a urinary tract infection include: dysuria, urinary frequency, urgency,
and pelvic pain. Signs of pregnancy may not be obvious, other than lengthened menstrual
period.
On examination, look for evidence of vaginal discharge or other infections. Signs of pregnancy, such as breast tenderness and enlarged uterus, may be present.
Diagnosis is based on urinalysis and urine culture. Urine hCG result should be positive if the
patient is pregnant. If pregnant, order routine initial pregnancy evaluation: CBC, type and
screen, RPR, rubella, Pap smear, HIV, hepatitis B, gonorrhea, chlamydia, and varicella.
Management
n
n
n
Antibiotics: For nonpregnant patients, trimethoprim/sulfamethoxazole or ciprofloxacin. For
pregnant patients, use amoxicillin, ampicillin, or cephalexin.
Supportive treatment: Counseling.
Pregnancy management if appropriate: Counseling, prenatal vitamins.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Abdomen, Genitalia
•Urinalysis
•Urine Gram stain
•hCG, beta, urine, qualitative
•Urine culture
THERAPY
•Antibiotic (TMP/SMX if not
pregnant; amoxicillin if pregnant)
•Exam: Additional ± Complete
•If patient pregnant and this is the first
visit, order:
•CBC
•Type and screen, blood
•Rubella serology
•RPR, serum
•Hepatitis B surface antigen, serum
•HIV test, ELISA, serum
•Pap smear
•Cervical DNA probe test, chlamydia
•Cervical DNA probe test, gonorrhea
•Varicella-zoster virus, IgG antibody
•Counsel patient
•Advise patient, prenatal counseling
•Prenatal vitamins
MONITORING
LOCATION
TIMING
•Urinalysis at each subsequent visit.
•Manage as outpatient unless there are signs of pyelonephritis.
•Management should be instituted within 2 hours of simulated time. Do not wait
until urine culture results to start antibiotics.
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
Abdomen, Genitalia ± Others
hCG, Urinalysis, Urine Gram stain, Urine culture
Advance clock to results or urinalysis.
Antibiotic (as above); if pregnant order: CBC, Type and screen,
Rubella, RPR, Hep B surface antigen, HIV, Pap smear, Gonorrhea
DNA, Chlamydia DNA, Advise patient prenatal counseling,
Prenatal vitamins
Reschedule patient in one month and advance clock for results,
additional patient updates and case end.
None
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
267
Case #110
Location: Office
Chief Complaint: Breast lump
Case introduction
Initial vital signs
Initial history
•A 24 -year-old Latina woman arrives at the office for a 3-month history of a
right breast mass.
•Unremarkable
•The patient has felt a firm, mobile mass in her right breast for the past 3
months. The mass is nontender and sometimes appears to increase in size.
She has noticed other ill-defined small lumps in her left and right breasts, but
the right breast lump feels more firm and well defined. She has not experienced any nipple discharge. There is no family history of breast cancer. She
has normal 28-day menstrual cycles. She is not sexually active. She does not
smoke, drink alcoholic beverages, or use illegal drugs.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
Breast
Right breast with a firm, mobile mass in the lower, inner quadrant. No skin
dimpling or retraction. Left breast with bumpy texture but no masses.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus normal in size. No adnexal
masses or tenderness.
What is the suspected diagnosis, and what are the next steps in management?
268
II—CCS CASES BY CHIEF COMPLAINT
Case #110: Fibroadenoma
Keys to Diagnosis
n
n
n
Look for a young woman in her teens or 20s who presents with a painless, firm breast mass.
Family history of breast cancer may or may not be present.
On exam, the mass is typically firm and mobile.
Ultrasound and biopsy (or aspirate) will generally lead to the diagnosis. Consider getting a
urine hCG because pregnancy may affect the decision to order mammography. (In general,
mammography is regarded as safe during pregnancy; however, it has a higher false-negative
rate. For the CCS, it is better to avoid mammography if the patient is pregnant.)
Management
n
n
Reassurance is generally the treatment of choice.
Surgical excision can be performed if the mass is large (>5 cm) or if it is bothersome to the
patient.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: Breast, Lymph nodes, Genitalia
•Exam: Additional ± Complete
•Breast ultrasound
•Mammography
•Breast fine-needle aspirate (or biopsy)
•hCG, urine, qualitative
•Reassure patient or Consult, surgery if appropriate
•Monitor symptoms as needed.
•Manage as outpatient.
•The diagnosis and management should be completed within 4 days of
simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
General, Skin, Breast, Lymph nodes, Genitalia ± Others
Breast ultrasound, hCG urine qualitative
Advance clock to hCG and ultrasound results.
Mammography (if not pregnant), Breast fine-needle aspirate
Advance clock to reschedule patient after all results are reported.
Reassure patient, Counsel patient
Advance to additional patient updates and case end.
None
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
269
Case #111
Location: Office
Chief Complaint: Breast lump
Case introduction
Initial vital signs
Initial history
•A 53-year-old white woman arrives at the office for a 2-month history of a firm
right breast mass.
•Unremarkable
•The patient first noticed the mass in her right breast 2 months ago while in
the shower. The mass is firm and nonmobile. She occasionally feels some
inflammation and tenderness around the area but not severe pain. She has
not noticed any other masses in the left or right breast, and she has not
experienced any nipple discharge. She has never had a mammogram.
There is no family history of breast cancer. She underwent menopause at age
51 years.
•Past medical history is unremarkable.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Breasts, Lymph nodes, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
Breast
Right breast with firm, nonmobile mass in the upper, outer quadrant. Skin
dimpling and retraction in the area of the mass. Left breast with no
masses. No nipple discharge.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
270
II—CCS CASES BY CHIEF COMPLAINT
Case #111: Breast Cancer
Keys to Diagnosis
n
n
n
Look for a woman with a unilateral breast mass. The presentation typically is in an older
female, but can also present in a younger woman. The mass is typically firm and nonmobile.
On exam, look for a firm, nonmobile mass. Also, in a reproductive-age patient, watch for
signs of pregnancy, such as bilateral breast tenderness or an enlarged uterus.
Mammography, ultrasound, and biopsy should lead to the diagnosis. If the patient has irregular menses or signs to suggest pregnancy, order a urine hCG and avoid mammography.
Management
n
n
n
Surgery, chemotherapy, and radiation are all used for management depending on the stage. If
the patient is pregnant, radiation and chemotherapy are generally avoided, and surgery is the
mainstay of therapy.
Counseling regarding cancer diagnosis.
Order routine pregnancy labs if patient is pregnant.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Breast, Lymph nodes
•Breast ultrasound
•Breast fine-needle aspirate
THERAPY
•Exam: Additional ± Complete
•Mammography
•hCG, beta, urine, qualitative
(if reproductive female)
•Reassure patient
•Advise patient, cancer diagnosis
•Consult, general surgery
•Consult, hematology/oncology
•Consult, radiation therapy
•Not important for this case.
•Office, managed as an outpatient.
•Management should be instituted within 4 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
End Orders
General, Skin, Breast, Lymph nodes ± Others
Mammography, Breast ultrasound, Breast fine-needle aspirate
Advance clock to reschedule patient when all results are reported.
Advise patient cancer diagnosis, Reassure patient, Consult general
surgery, Consult hematology/oncology, Consult radiation therapy
Advance to additional patient updates and case end.
None
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
271
Case #112
Location: Office
Chief Complaint: Amenorrhea
Case introduction
Initial vital signs
Initial history
•A 33-year-old white woman arrives at the office for a 4-month history of
amenorrhea.
•Height: 168 cm (66.0 in)
•Weight: 96.3 kg (212.3 lb)
•Body mass index: 34.1 kg/m2
•The patient has been having irregular periods for the past year with menstrual
cycles lasting up to 40 days but now has stopped having periods for the past
4 months. She has taken several over-the-counter pregnancy tests, and the
results have all been negative. In addition, she has also experienced
increased hair growth on her face, abdomen, and underarms. She has
recently noticed increased acne appearing on her face and some hair loss on
her scalp. She has had weight gain of about 25 lb over the past 6 months.
•Past medical history includes two normal childbirths 4 and 6 years ago.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Obese female; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Increased hair on face and
abdomen.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Obese abdomen. Bowel sounds normal; no bruits. No masses or tenderness.
Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus normal in size. Left adnexal
mass without tenderness.
What is the suspected diagnosis, and what are the next steps in management?
272
II—CCS CASES BY CHIEF COMPLAINT
Case #112: Polycystic Ovary Disease
Keys to Diagnosis
n
n
n
Look for a young adult woman with recent-onset secondary amenorrhea. Additional symptoms include hirsutism, abnormal vaginal bleeding, infertility, acne, and weight gain. Vital
signs may show increased BMI or hypertension.
On exam, look for increased hair growth, obesity, skin thickening, and hyperpigmentation
(acanthosis nigricans); enlarged ovaries on genitalia exam.
Diagnosis is made by exclusion of other causes, lab tests showing elevated androgen levels
(high LH, high testosterone), and ultrasound showing ovarian enlargement. Also evaluate
for insulin resistance, dyslipidemia, and hypothyroidism.
Management
n
n
n
Medical treatment involves treating menstrual irregularities, hirsutism and insulin resistance.
Multiple options exist. Typical first-line agents include Metformin and Oral contraceptives.
If fertility is desired, replace oral contraceptives with Clomiphene.
Counseling regarding weight reduction with diet and exercise.
Surgery is considered if medical treatment fails.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•hCG, beta, urine, qualitative
•Lipid profile
•Transvaginal ultrasound
•TSH, serum
•Prolactin, serum
•DHEA-S, serum
•FSH, serum
•Estrogens, total, blood
•LH, serum
•Androstenedione, serum
•Testosterone, serum
•Cortisol, 24-hour urine free (to rule
•Fasting plasma glucose
out Cushing’s syndrome)
•Metformin, oral
•Consult, endocrinology
•Oral contraceptive, high estrogen/
•Advise patient, exercise program
high progestin (Clomiphene if fertility
•Weight loss diet
desired)
•Monitor weight and exam findings on follow-up visits
•Manage as outpatient.
•Management should be instituted within 1-2 weeks of simulated time.
Exam
Orders
Clock
Orders
Complete
hCG beta urine qualitative
Advance to results of hCG.
Transvaginal ultrasound, Prolactin, FSH, LH, Testosterone, Fasting
plasma glucose, Lipid profile, TSH, DHEA-S, Estrogens total,
Androstenedione, Cortisol 24 hour urine free
Clock
Reschedule patient after all results have been reported.
Orders
Oral contraceptive high estrogen/high progestin (or Clomiphene),
Metformin, Consult endocrinology, Weight loss diet, Advise patient
exercise program
Clock
Reschedule patient monthly for additional results, patient updates
and case end.
End Orders None
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
273
Case #113
Location: Office
Chief Complaint: Vulvar itching
Case introduction
Initial vital signs
Initial history
•A 59-year-old white woman arrives at the office for a 2-week history of vulvar
itching and pain.
•Unremarkable
•The patient has experienced increased vulvar itching and dryness over the past
2 weeks. The itching has caused increased pain related to scratching. There
has been no vaginal discharge or bleeding. She underwent menopause at age
54 years and has not had these symptoms in the past. She has not been
sexually active since becoming a widow 2 years ago.
•Past medical history includes hypercholesterolemia and three childbirths.
•Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, Chest, Heart, Abdomen, Genitalia
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Raised, fleshy white lesion on the labia majora. No vaginal or cervical lesions.
Uterus not enlarged. No adnexal masses or tenderness.
What is the suspected diagnosis, and what are the next steps in management?
274
II—CCS CASES BY CHIEF COMPLAINT
Case #113: Vulvar Carcinoma
Keys to Diagnosis
n
n
n
Look for a postmenopausal woman with vulvar itching, pain, bleeding, or discharge.
On exam, there may be a raised, fleshy, warty, ulcerated, or white lesion.
Diagnosis is based on biopsy, with squamous cell carcinoma being most common. Evaluation
of vagina and cervix may help determine extent of spread. Evaluation of the groin lymph
nodes should be performed.
Management
n
n
n
Therapy is based on the size, extent of invasion, and presence of lymph node involvement.
Staging with imaging of the chest, abdomen, and pelvis.
Treatment can involve surgery, radiation therapy, or chemotherapy, depending on the stage
of disease.
Counseling and reassurance.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Genitalia
•Vulvar biopsy
THERAPY
•Consult, Ob/Gyn (or vulvectomy)
•Advise patient, cancer diagnosis
•Pap smear
•CT, abdomen/pelvis
•CT, chest
•Consult, hematology/oncology
•Consult, radiation therapy
•Reassure patient
MONITORING
LOCATION
TIMING
•Not important for this case.
•Manage as outpatient.
•Diagnosis and therapy should be instituted within 4 days of simulated time.
SEQUENCING
Exam
Orders
Clock
Orders
Genitalia, lymph nodes ± Additional
Vulvar biopsy, Pap smear
Advance clock to schedule patient after results of biopsy.
Advise patient cancer diagnosis, Consult Ob/Gyn, Consult
hematology/oncology, Consult radiation therapy, CT abdomen/
pelvis, CT chest
Clock
Advance clock to additional results and case end.
End Orders None
21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES
275
Key Points—Miscellaneous Obstetrics/Gynecology
Cases
n
n
or a reproductive-age woman, always consider ordering a urine hCG for pregnancy. It
F
is not uncommon for a CCS case to present as UTI or breast mass but then also have an
unrecognized new pregnancy.
For a newly pregnant patient, order the following screening studies:
n CBC
n Urinalysis
n Type and screen, blood
n Rubella serology
n RPR, serum
n Hepatitis B surface antigen, serum
n HIV test, ELISA, serum
n Pap smear
n Cervical DNA probe test, chlamydia
n Cervical DNA probe test, gonorrhea
n Varicella-zoster virus, IgG antibody
C H A P T E R
22
Pediatric Fever
Key Orders*
Order
CCS Terminology
Pulse oximetry
Chest X-ray, portable
ABG
Lumbar puncture
CBC with differential
Urinalysis
CSF, Gram stain
CSF, protein
CSF, glucose
CSF, cell count
CSF, meningococcal antigen
Pulse oximetry
X-ray, chest, AP, portable
Arterial blood gases
Lumbar puncture
CBC with differential
Urinalysis
Gram stain, cerebrospinal fluid
Protein, cerebrospinal fluid
Glucose, cerebrospinal fluid
Cell count, cerebrospinal fluid
Antigen, meningococcal,
cerebrospinal fluid
Bacterial culture, urine
Bacterial culture, cerebrospinal
fluid
Bacterial culture, blood
Urine culture
CSF, culture, bacterial
Blood culture
Time to Results—ED
Setting (Stat)
1 min
10 min
18 min
20 min
30 min
30 min
40 min
50 min
50 min
50 min
5 hours 20 min
24 hr
24 hr 20 min
30 hr
*All orders in both columns can be recognized by the USMLE CCS Primum® software
277
22—PEDIATRIC FEVER
Case #114
Location: Office
Chief Complaint: Fever
Case introduction
Initial vital signs
Initial history
•A 3-year-old white girl is brought to the office by her mother for a 3-day history of fever.
•Temperature: 40.1 degrees C (104.1 degrees F)
•The patient has experienced fever over the past 3 days with temperatures
between 100 and 104 degrees F at home. The mother says her child started
experiencing cold symptoms with a sore throat and runny nose about
5 days ago, which has now mostly resolved. Today she complained of a mild
headache and fatigue. The child has not complained of ear pain, cough, or
shortness of breath. The mother says the child had a cold 6 months ago and
was given antibiotics, so she would like to have antibiotics now as well.
•Past medical history of eczema. All vaccinations are up to date.
•Family history, developmental history, and review of systems are un­
remarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Skin feels warm with normal turgor. No nodules or other lesions. Hair and
nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms,
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
278
II—CCS CASES BY CHIEF COMPLAINT
Case #114: Erythema Infectiosum (Fifth Disease)
Keys to Diagnosis
n
n
n
The typical presentation is fever in a child younger than 5 years of age. Look for increased
temperature on initial vital signs. The child may have no other symptoms or may complain
of nausea, headache, sore throat, runny nose, itching, or arthralgia. On the CCS, a parent or
caregiver may appear pushy or upset, encouraging you to give an antibiotic.
The initial exam is often unremarkable. The classic “slapped face” rash may not be present
until subsequent follow-up examination.
The typical workup for a child with fever is based on age, temperature, and whether he or
she ­appears toxic. The diagnosis of erythema infectiosum is clinical. Imaging and labs are
generally not needed.
Management
n
n
n
Treatment is supportive. The illness is typically self-limited, lasting 1 to 2 weeks.
Do not give antibiotics.
Follow-up every 24 to 48 hours to monitor temperature, symptoms, and exam.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•Exam: Skin, HEENT.
THERAPY
•Follow-up exam: Skin, HEENT
•If fever >39° C, Consider CBC, Urinalysis and
Urine culture
•NSAIDs if arthralgia
•Reassure patient/family
•Counsel parent
•Monitor temperature and exam in 24 to 48 hours.
•The typical case of fifth disease can be treated as an outpatient.
•The diagnosis may take several days to confirm until the fever subsides and the
classic rash appears on the face.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Orders
Clock
Orders
Clock
Exam
Orders
Clock
End Orders
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities ±
Others
CBC, Urinalysis, Urine culture
Advance clock to results of CBC, urinalysis
Reassure patient/family, Counsel parent
Reschedule patient in 2 days.
Skin, HEENT ± Others
Reassure patient/family, Counsel parent
Advance clock to additional patient updates and case end.
None
279
22—PEDIATRIC FEVER
Case #115
Location: Emergency Department
Chief Complaint: Fever, vomiting
Case introduction
Initial vital signs
Initial history
•A 5-month old Latina girl is brought the emergency department by her mother
for a 2-day history of increasing fever and vomiting.
•Temperature: 40.3 degrees C (104.5 degrees F)
•The mother says her child has been having worsening fever over the past 2 days
and has experienced two episodes of vomiting today. She has had difficulty
feeding her, and her child has appeared lethargic and tired despite little activity.
She also has had difficulty sleeping and has been increasingly fussy. No one
else in the household or her day care center is known to be ill.
•Past medical history is unremarkable.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Child resting in mother’s arms; appears somnolent and lethargic.
Skin
Skin feels warm with normal turgor. Purpuric rash on the buttocks and legs.
Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Funduscopic examination with papilledema. Ears, including
pinnae, external auditory canals, and tympanic membranes, normal. Nose
and mouth normal. Pharynx normal. Neck supple; no masses or bruits;
thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
280
II—CCS CASES BY CHIEF COMPLAINT
Case #115: Meningococcal Meningitis
Keys to Diagnosis
n
n
n
The presentation in a child is typically high fever with other nonspecific symptoms, such as
vomiting, difficulty feeding, fussiness, lethargy, stupor, seizures, and apnea. On vital signs,
look for high temperature with possible hypotension or tachycardia.
On exam, look for purpuric rash on the skin or extremities. Also look for nuchal rigidity,
papilledema, or dilated pupils on the HEENT exam and bulging fontanelles in infants.
CT or MRI of the head if increased intracranial pressure, coma, or neurologic deficits. CSF
studies will lead to the diagnosis. On CSF, look for opening pressure >100 mm Hg, low
glucose, high protein, cell count with predominant neutrophils, and positive meningococcal
antigen. On Gram stain, look for gram-negative diplococci (Neisseria meningitidis) or grampositive cocci in pairs (Streptococcus pneumoniae) if pneumococcal meningitis.
Management
n
n
n
Empiric antibiotics should be started after cultures and before results of studies. Several options are available. One option is to use a third-generation cephalosporin (e.g., ceftriaxone)
plus Vancomycin as empiric therapy. Acetaminophen to help reduce fever.
Bacterial meningitis should be reported to the public health department.
Admission to the inpatient unit or ICU. Monitor temperature and vital signs.
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
OPTIMAL ORDERS
ADDITIONAL ORDERS
•CBC
•Blood culture
•Lumbar puncture
•CSF, Gram stain
•CSF, culture, bacterial
•CSF, cell count
•CSF, glucose
•CSF, protein
•CSF, meningococcal antigen
•Antibiotics (Ceftriaxone plus
vancomycin)
•BMP
•LFT
•Chest X-ray, PA/lateral
•Urinalysis
•Urine culture
•Notify public health department
•Consult, pediatric infectious disease
•Acetaminophen, therapy
•Temperature
•Vital signs
•Change to inpatient unit if patient stable, ICU if vital signs unstable.
•Therapy should be instituted within 30 minutes of simulated time. Do not wait
for lab results to begin empiric antibiotic therapy.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
Location
Clock
End Orders
General, Skin, HEENT, Heart, Lungs ± Others
CBC, Blood culture, BMP, LFT, Urinalysis, Urine culture, Lumbar
puncture, CSF studies (gram stain, culture, glucose, protein, cell
count, meningococcal antigen)
Advance clock to results of CSF gram stain.
Ceftriaxone, Vancomycin, Acetaminophen, Consult pediatric
infectious disease
Advance to additional results.
Notify public health department, Vital signs, Counsel parent
Advance to vitals sign results.
Change to inpatient unit or ICU as appropriate
Advance to additional results, patient updates and case end.
None
22—PEDIATRIC FEVER
281
Case #116
Location: Office
Chief Complaint: Fever and fussiness
Case introduction
Initial vital signs
Initial history
•A 9-month-old African-American boy arrives at the office with his mother for a
2-day history of irritability, fussiness, and fever.
•Temperature: 38.8 degrees C (101.8 degrees F)
•The mother describes increasing irritability and fussiness beginning two days
ago. Last night, he had trouble falling asleep and woke up several times during
the night. He has been feeding normally and has not had any vomiting. He had
one episode of shaking chills last night, but has not experienced shortness of
breath, coughing or wheezing. He does not have a history of infections or previous visits to the emergency department.
•Past medical history is unremarkable.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Ear examination shows right sided bulging, erythematous tympanic
membrane. Nose and mouth normal. Pharynx normal. Neck supple; no
masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
282
II—CCS CASES BY CHIEF COMPLAINT
Case #116: Otitis Media
Keys to Diagnosis
n
n
n
In young children, look for nonspecific symptoms, such as fever, chills, irritability, fussiness,
difficulty feeding, vomiting and lethargy. Typical symptoms, such as ear pain, pulling on the
ear, and difficulty hearing, may not be present. Vital signs show fever.
On examination, look for tympanic membrane abnormalities on HEENT exam.
Unless the patient appears toxic, additional lab and imaging tests are generally not needed.
Management
n
n
n
Antibiotics: If younger than 2 years of age, use antibiotics for 5 to 7 days. If older than
2 years, can use observation if nonsevere illness or antibiotics if more severe illness. Amoxicillin is the first-line drug of choice. If no response in 3 days, change to amoxicillin/clavulanate
or second-generation cephalosporin (e.g., cefuroxime).
Supportive: fever reduction as needed, hydration, and avoid irritants (tobacco smoke).
Treat as outpatient unless there is evidence of meningitis or sepsis.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: General, HEENT
•Amoxicillin therapy, oral,
continuous
•Exam: Additional
•Acetaminophen, therapy
•Counsel parent
•Reassure patient
•Normally follow-up in 4–6 weeks to evaluate HEENT exam.
•Most uncomplicated cases can be managed as an outpatient.
•Management should be instituted within 1 day of simulated time.
Exam
Orders
Clock
End Orders
General, HEENT ± Additional
Amoxicillin, Acetaminophen, Counsel parent, Reassure patient
Advance clock 1 week for patient updates and to cancel
antibiotics. Then reschedule patient in 4–6 weeks for additional
patient updates and case end.
None
283
22—PEDIATRIC FEVER
Pediatric Fever—Key Points
n
n
n
n
he diagnostic evaluation of a pediatric patient with fever is dependent on age, temperature
T
and appearance (Table 22-1).
For pediatric patients 1 month to 3 years of age who present to the office with a fever >39° C
and appear nontoxic, in general, order a CBC, urinalysis, and urine culture (Table 22-1).
The results of the CBC and urinalysis can be seen at the first visit.
If the CBC shows WBC >15,000/mm3 or ANC >10,000/mm3, consider changing location
to inpatient unit, completing workup with blood cultures and CSF studies, and starting
antibiotic therapy.
If the WBC and ANC are not elevated, follow up in 24 hours and manage with observation.
TABLE 22-1 n General Diagnostic Evaluation of Fever in a Child
Age
Temperature
Appearance
Workup
<1 month
>38° C
Toxic or nontoxic
CBC
Urinalysis
Urine culture
Blood culture
CSF, gram stain
CSF, culture
CSF, protein
CSF, glucose
CSF, cell count
>1 month
>38° C
Toxic
CBC
Urinalysis
Urine culture
Blood culture
CSF, gram stain
CSF, culture
CSF, protein
CSF, glucose
CSF, cell count
1–3 months
>39° C
Nontoxic
CBC
Urinalysis
Urine culture
Optional:
Blood cultures
Stool studies
Chest X-ray
CSF studies
3–36 months
>39° C
Nontoxic
Optional:
CBC
Urinalysis
Urine culture
3–36 months
38° C–39° C
Nontoxic
Observation
C H A P T E R
23
Miscellaneous Pediatric Cases
Key Orders*
Order
CCS Terminology
Urinalysis
Urinalysis
BMP
Basic metabolic profile
ECG, 12-lead
Electrocardiography, 12-lead
Echocardiography
Echocardiography
Abdominal ultrasound
US, abdomen
Fasting blood glucose
CBC with differential
Glucose, serum, fasting
CBC with differential
Retic count
Reticulocyte count, blood
LDH, serum
Lactate dehydrogenase, serum
Bilirubin, serum, total and direct
Bilirubin, serum, total and direct
Audiometry
LFT
Coombs’ test, direct
Audiometry
Liver function panel
Antiglobulin test, direct, complement,
blood
Antiglobulin test, indirect, blood
Heinz body stain
G-6-PD, blood, quantitative
Coombs’ test, indirect
Heinz body stain
Glucose-6-phosphate
dehydrogenase, blood, quant
Haptoglobin, serum
Calcium, ionized, serum
Urine protein, 24-hour quantitative
Lipid profile
Serum C3 complement
Bone age
TSH, serum
Albumin, serum
Karyotype
FSH, serum
LH, serum
Haptoglobin, serum
Ionized calcium, serum
Protein, 24-hour urine, quantitative
Lipid profile
Complement, C-3, serum
Bone age
Hormone, thyroid-stimulating, serum
Albumin, serum
Chromosome analysis, karyotype
Hormone, follicle-stimulating, serum
Hormone, luteinizing, serum
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
Time to Results—
Office Setting
30 min (stat),
6 hr (routine)
30 min (stat),
2.5 hr (routine)
15 min (stat),
30 min (routine)
30 min (stat),
4 hr (routine)
30 min (stat),
4 hr (routine)
1 hr
1 hr (stat),
4 hr (routine)
1 hr (stat),
4 hr (routine)
1 hr (stat),
4 hr (routine)
1 hr (stat),
4 hr (routine)
1 hr
2.5 hr
6 hr
6 hr
8 hr
8 hr
10 hr
12 hr
24 hr
24 hr
24 hr
24 hr
2 days
2 days
3 days
3 days
8 days
23—MISCELLANEOUS PEDIATRIC CASES
285
Case #117
Location: Office
Chief Complaint: Short stature
Case introduction
Initial vital signs
Initial history
•A 14-year-old white girl is brought to the office by her mother for a history of
short stature.
•Height: 138 cm (54.3 in)
•Weight: 59.0 kg (143.3 lb)
•Body mass index: 31.4 kg/m2
•The mother states her daughter has always been short compared with her
friends, but it has become more noticeable over the past year. She does well
in school and has normal intelligence for her age. She participates in several
sports and after-school activities. She has not had her first period, although all
of her friends have. She does not have a history of infections, diarrhea, shortness of breath or significant problems as a child.
•Past medical history is unremarkable.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Short, overweight female; In no apparent distress.
Skin
Normal turgor. Nevi present on arms and back. Hair and nails normal.
Breasts
Nipples widespread with reduced breast development for age; no masses.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. High arched palate present. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. Soft systolic heart murmur. Central and peripheral pulses
normal. No jugular venous distention. Blood pressure equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal labia with decreased pubic hair for age. No vaginal or cervical lesions.
Uterus not enlarged. No adnexal masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
286
II—CCS CASES BY CHIEF COMPLAINT
Case #117: Turner Syndrome
Keys to Diagnosis
n
n
n
Typical symptoms in older children include short stature; primary amenorrhea; delayed
­secondary sex characteristics; and, less commonly, learning disabilities.
On exam, look for high-arched palate, widespread nipples, delayed breast and pubic hair
development, heart murmurs, hypoplastic nails, nevi, and lymphedema.
Diagnosis is made by chromosome analysis, which reveals 45,XO karyotype. Although
buccal smear for Barr bodies is an option on the CCS, it is no longer commonly used.
Echocardiography may show a bicuspid aortic valve, coarctation of the aorta, or aortic stenosis. Other comorbid conditions to look for include horseshoe kidneys, hypothyroidism,
diabetes ­mellitus, hearing loss and osteoporosis.
Management
n
n
n
Medications: Growth hormone therapy for short stature (if bone age <14 years), Estrogen
therapy for puberty (assess LH and FSH before starting), Calcium and Vitamin D therapy
for Osteoporosis.
Obesity management with weight loss diet and exercise.
Counseling and Consultation with genetics, pediatric endocrinology, cardiology, nephrology
and clinical psychology, as appropriate.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam: HEENT, Breast, Heart, Genitalia
•Follicle-stimulating hormone
•Karyotype
•Luteinizing hormone
•TSH, serum
•Bone age
•Fasting glucose
•BMP
•Echocardiography
•LFT
•Abdominal ultrasound
•Audiometry
•Growth hormone therapy, SQ
•Consult, genetics
•Estrogen conjugated
•Consult, pediatric cardiology
•Consult, pediatric endocrinology
•Consult, pediatric nephrology
•Advise patient, exercise program
•Consult, clinical psychology
•Diet, high calcium
•Advise, patient estrogen
•Calcium carbonate, oral
therapy
•Vitamin D, therapy
•Reassure patient
•Weight loss diet
•Although not important for the time frame of this case, thyroid, glucose, and
other parameters are monitored on a routine basis.
•Most patients can be treated as an outpatient.
•Management should be instituted within 4 days of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
Complete
Karyotype, TSH, Fasting glucose, FSH serum, LH serum,
Echocardiography, Audiometry, Abdominal ultrasound, Bone age,
BMP, LFT
Advance clock to reschedule patient when all results are reported.
Growth hormone therapy, Estrogen conjugated, Calcium
carbonate, Vitamin D therapy, Weight loss diet, Diet high
calcium, Advise patient estrogen therapy, Advise patient side
effects of medication, Advise patient exercise program, Consult
pediatric endocrinology, Consult genetics, Consult pediatric
nephrology, Consult pediatric cardiology, Reassure patient
Advance to additional results, patient updates and case end.
None
23—MISCELLANEOUS PEDIATRIC CASES
287
Case #118
Location: Office
Chief Complaint: Jaundice
Case introduction
Initial vital signs
Initial history
•A 5-year-old white boy is brought to the office by his father for a 5-day history
of jaundice.
•Unremarkable
•The boy’s father noticed increasing yellowness of the skin and eyes over the
past several days. In addition, he has had fatigue and seems to sleep more
and get tired easily. He had an upper respiratory tract infection and otitis media
1 week ago and was placed on trimethoprim/sulfamethoxazole. Symptoms
related to his infection have improved.
•Past medical history is unremarkable.
•Family history includes a history of jaundice in a maternal grandfather.
•Developmental history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no acute distress.
Skin
Normal turgor with jaundice. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes show scleral icterus. Hearing normal.
Ears, including pinnae, external auditory canals, and tympanic membranes,
normal. Nose and mouth normal. Pharynx normal. Neck supple; no masses
or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
288
II—CCS CASES BY CHIEF COMPLAINT
Case #118: Glucose-6-Phosphate Dehydrogenase
Deficiency
Keys to Diagnosis
n
n
n
The typical presentation is jaundice, but symptoms can include irritability, nausea, abdominal
pain, diarrhea, fatigue and shortness of breath. Look for a history of recent infection or new
medication. Since it is X-linked recessive, look for a family history of affected male members.
On exam, evidence of jaundice should be present with scleral icterus. Splenomegaly or hepatomegaly may be present.
CBC shows normocytic anemia with presence of bite cells. Reticulocytes are increased.
Laboratory studies show evidence of hemolysis: increased LDH and bilirubin and decreased
haptoglobin. Diagnosis is confirmed by evaluation of Heinz body stain or glucose-6-phosphate dehydrogenase ­activity.
Management
n
n
n
Discontinuation of the triggering agent is the primary treatment. If a new medication was
recently started (typically an antibiotic), cancel it.
The primary therapy is supportive with bed rest.
If severe anemia, admit to inpatient unit for IV fluids, oxygen and possibly transfusion. Hemolysis is generally short lived, and most patients do not require transfusion.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•CBC
•Haptoglobin
•Reticulocyte count
•LFT
•LDH, serum
•BMP
•Bilirubin, total and direct
•Urinalysis
•Heinz body stain
•Coombs’ test, direct
•G-6-PD, blood quantitative
•Cancel any potential causative medications
•Consult, pediatric
•Counsel patient/family
hematology/oncology
•Advise patient, rest at home
•Reassure patient
•Consult, genetics
•Oxygen
•CBC
•Admit to hospital if treatment requires oxygen, IV fluids, or transfusion.
•Management should be instituted within 1 day of simulated time.
Exam
Orders
Clock
Location
Orders
Clock
Orders
Clock
End Orders
General, Skin, HEENT, Heart, Lungs, Abdomen ± Complete
CBC, Retic count, LDH, Bilirubin—all ordered stat
Advance to results.
Change to inpatient unit if severe anemia present.
Cancel any potential causative medications, Haptoglobin,
Heinz body stain, G-6-PD quantitative, LFT, BMP, Urinalysis,
Coombs’ test direct, Advise patient rest at home
Advance clock to reschedule patient in 1 day.
Consult pediatric hematology/oncology, Consult genetics,
Counsel patient/family, Reassure patient
Advance to additional results, patient updates and case end.
None
23—MISCELLANEOUS PEDIATRIC CASES
289
Case #119
Location: inpatient unit
Chief Complaint: Vomiting
Case introduction
Initial vital signs
Initial history
•You are called to the neonatal inpatient unit to see a 7-hour-old white newborn boy with vomiting and difficulty feeding.
•Unremarkable
•The patient was born 7 hours ago by normal vaginal delivery. At delivery, the
patient had normal Apgar scores, and no complications were reported. The
mother of the infant is a 38-year-old woman who has not had any prenatal
care. This is her first child. The mother reports difficulty getting the infant to
latch on to her nipples and feed. The infant has vomited every time feeding
has been attempted and the vomitus was noted to be billous.
•Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, HEENT, Chest, Heart, Abdomen, Genitalia, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Newborn infant, crying.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
HEENT/Neck
Normocephalic. Eyes are not open and show prominent epicanthal folds. Ears
appear low set but are otherwise normal. Nose shows a depressed nasal
bridge. Pharynx normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Extremities/Spine
Extremities symmetric without cyanosis or clubbing. Single palmar crease on
both hands. Peripheral pulses normal. No joint deformity or warmth; full
range of motion. Spine examination normal.
Neuro/Psych
Alert; neurologic findings normal.
What is the suspected diagnosis, and what are the next steps in management?
290
II—CCS CASES BY CHIEF COMPLAINT
Case #119: Down Syndrome; Duodenal Atresia
Keys to Diagnosis
n
n
n
In neonates, symptoms include vomiting from duodenal atresia, absence of stools from
Hirschsprung disease, heart murmur from ventricular or atrial septal defect, or abnormal
facies. In older children, the presentation may be related to abnormalities in hearing, vision,
developmental delay, infections, delays in cognitive abilities, and behavioral changes.
On exam, look for abnormalities on HEENT exam: epicanthal folds; nystagmus; flat nasal
bridge; tongue protrusion; and small, low-set ears. On heart exam, there may be a murmur
from congenital heart defect.
Diagnosis is based on cytogenetic evaluation showing a trisomy 21 karyotype. For
duodenal atresia, plain abdominal radiograph shows a typical “double-bubble” sign. Abdominal ultrasound or upper GI series can be considered if the diagnosis is in doubt or to exclude
other causes, such as a midgut volvulus. For a heart murmur, order echocardiography. Order
CBC to look for leukemia.
Management
n
n
n
Treatment for duodenal atresia is surgery. Nasogastric tube to remove any contents and IV
fluids.
A thyroid screen should be performed at birth as well as evaluating for additional abnormalities.
Consult genetics, pediatric cardiology or pediatric endocrinology as indicated.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Exam
•Karyotype
•Abdominal X-ray, plain
•TSH
•CBC
•BMP
•Echocardiography
•Abdominal ultrasound or
Upper GI series
•Consult, pediatric surgery
•Consult, pediatric cardiology
•Nasogastric tube
•Consult, genetics
•Intravenous access
•Consult, pediatric
•Normal saline, 0.9% NaCl
endocrinology
•Not important for the time frame of this case.
•Transfer to ICU if unstable vital signs or cyanotic.
•Management should be instituted within 1 day of simulated time.
Exam
Orders
Clock
Orders
Clock
End Orders
HEENT, Cardiac, Lung ± Complete
Abdominal X-ray
Advance clock to results of X-ray.
Consult pediatric surgery, Nasogastric tube, Intravenous
access, Normal saline 0.9% NaCl, Karyotype, TSH, CBC,
BMP, Echocardiography
Advance to additional results, patient updates and case end.
Consult genetics, Consult pediatric cardiology, Consult
pediatric endocrinology
23—MISCELLANEOUS PEDIATRIC CASES
291
Case #120
Location: Office
Chief Complaint: Facial swelling and edema
Case introduction
Initial vital signs
Initial history
•A 4-year-old white boy arrives at the office with his mother for a 5-day history of facial swelling.
•Unremarkable
•The mother reports gradual swelling predominantly around the eyes and
mouth, initially thought to be related to allergies. In the past 2 days, she has
noticed swelling of the scrotum and lower extremities as well. The patient
had an upper respiratory tract infection 2 weeks ago that resolved on its
own. He has never had these symptoms before. No one else in the household has reported similar symptoms.
•Past medical history includes being born by normal vaginal delivery without
complications.
•Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
•General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
HEENT/Neck
Normocephalic. Vision normal. Eyes show periorbital swelling. Hearing normal.
Ears, including pinnae, external auditory canals, and tympanic membranes,
normal. Nose normal. Mouth shows perioral swelling. Pharynx normal. Neck
supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Genitalia
Normal circumcised penis; scrotal swelling present; testes without masses. No
inguinal hernia.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. 2+ pitting
edema. Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
Neuro/Psych
Alert; neurologic findings normal.
What is the suspected diagnosis, and what are the next steps in management?
292
II—CCS CASES BY CHIEF COMPLAINT
Case #120: Nephrotic Syndrome; Minimal Change
Disease
Keys to Diagnosis
n
n
n
Edema is the most common presentation, with swelling seen in the periorbital, perioral,
scrotal, labial, and abdominal areas and in the lower legs. Other symptoms include anorexia,
fatigue, irritability, abdominal discomfort, and diarrhea. A history of respiratory tract infection or allergies is frequent.
On exam, look for pitting edema and swelling in the face, abdomen, or genitals.
Diagnosis is established by urinalysis and urine protein quantitation with low albumin and
hyperlipidemia. Renal biopsy is generally not necessary unless initial treatment fails. ­Look
for abnormal electrolytes on BMP.
Management
n
n
n
Prednisone is the mainstay of therapy, generally for 6-8 weeks.
Edema is treated with low-sodium diet. Medication, such as hydrochlorothiazide (monitor
for hypokalemia) may be used in severe cases.
Newly diagnosed patients may be admitted for diagnostic and educational ­purposes.
­Immediate attention is required for severe scrotal edema, dehydration, peritonitis, or
­respiratory compromise caused by pulmonary edema.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•Urinalysis
•CBC
•Urine protein, 24-hour, quantitative
•BMP
•Albumin
•LFT
•Lipid profile
•Chest X-ray, PA/lateral
•Prednisone
•Counsel patient/family
•Diet, low sodium
•Reassure patient
•Monitor urinalysis, clinical exam, and any electrolyte abnormalities.
•Newly diagnosed patients are often admitted for diagnostic and educational
purposes.
•Management should be instituted within 2 days of simulated time.
Exam
Orders
Clock
Location
Orders
Complete
Urinalysis
Advance clock to results or urinalysis.
Change to inpatient unit.
Urine protein 24-hour quantitative, Albumin, Lipid profile, CBC, BMP,
LFT, Chest X-ray
Clock
Advance to results.
Orders
Prednisone, Diet low sodium, Counsel patient/family, Reassure
patient
Clock
Advance to additional patient updates.
Exam
HEENT, Genitalia
Orders
Urinalysis
Clock
Advance to additional results, patient updates and case end.
End Orders None
A P P E N D I X
CCS Cases Listed by Case
Number and Alphabetically
by Final Diagnosis
Case List by Number
Case Number
Final Diagnosis
Chapter 4 USMLE
­Primum® CCS Cases
1
2
3
4
5
6
Tension Pneumothorax
Rheumatoid Arthritis
Aortic Dissection
Asthma
Diabetic Ketoacidosis with
Sepsis
Eclampsia with Fetal
Distress
Chapter 5 ­Abdominal
Pain
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Pneumonia
Acute Appendicitis
Acute Pancreatitis
Sickle Cell Anemia with
Vaso-Occlusive Crisis
Ectopic Pregnancy
Gastroesophageal Reflux
Disease/Barrett’s
Esophagus
Intussusception
Sigmoid Volvulus
Small Bowel Obstruction
Adult Polycystic Kidney
Disease
Ovarian Cancer
Pelvic Inflammatory Disease
Peptic Ulcer Disease with
Perforation
Splenic Hematoma
Acute Diverticulitis
Mesenteric Ischemia
Chapter 6 Fatigue
23
24
25
26
27
28
29
30
31
32
33
34
Colon Cancer/Iron Deficiency
Anemia
Hypothyroidism
Diabetes Mellitus
Lead Poisoning/Iron Deficiency
Anemia
Pancreatic Cancer
Anorexia Nervosa
Renal Cell Carcinoma
Gastritis
Peptic Ulcer Disease
Vitamin B12/Folate Deficiency
Gastric Cancer
Acute Lymphoblastic
Leukemia
Chapter 7 Chest Pain
35
36
37
38
Acute Pericarditis
Panic Attack
Systemic Lupus Erythematosus
Stable Angina
Chapter 8 Altered
­Mental Status
39
40
41
42
43
44
45
46
47
Tricyclic Antidepressant
Overdose
Subarachnoid Hemorrhage
Benzodiazepine Overdose
Alzheimer’s Dementia
Toxic Shock Syndrome
Parkinson’s Disease
Hyperosmolar Hyperglycemic
State
Opioid Toxicity
Hepatic Encephalopathy
294
48
49
50
APPENDIX
Thrombotic Thrombocytopenic
Purpura (TTP)
Acetaminophen Overdose
Multiple Sclerosis
Chapter 9 Pain in the
Extremities
51
52
53
54
55
56
Child Abuse
Gout
Femoral Neck Fracture
Deep Vein Thrombosis (DVT)
Spousal Abuse
Septic Arthritis
Chapter 10 Cough
57
58
59
60
61
62
63
Foreign Body Aspiration
Lung Cancer
Pneumocystis carinii
Pneumonia/AIDS
Tuberculosis
Hodgkin Lymphoma
Laryngeal Cancer
Croup
(Laryngotracheobronchitis)
Chapter 11 Trauma
64
65
Cardiac Tamponade
Complete Heart Block
(Third-Degree
Atrioventricular)
Chapter 12 Shortness
of Breath
66
67
68
69
70
71
72
73
74
Anaphylaxis
Myocardial Infarction
Bronchiolitis
Dilated Cardiomyopathy
Congestive Heart Failure
Infective Endocarditis
Pulmonary Embolism
Aortic Stenosis
Chronic Obstructive Pulmonary
Disease (COPD)
Chapter 13 Back Pain
75
76
77
78
79
Prostate Cancer
Osteoporosis/Vertebral
Fracture
Abdominal Aortic Aneurysm,
Ruptured
Prostatitis, Acute Bacterial
Osteoarthritis
Chapter 14 Diarrhea
80
81
82
83
84
Crohn’s Disease
Irritable Bowel Syndrome
Cystic Fibrosis
Ulcerative Colitis
Giardiasis
Chapter 15 Headache
85
86
87
88
89
Temporal Arteritis/Polymyalgia
Rheumatica
Acute Sinusitis
Herpes Zoster (Shingles)
Depression
Hypertensive Emergency
Chapter 16 Bruising
90
91
92
Immune Thrombocytopenic
Purpura (ITP)
Elder Abuse
Hemophilia
Chapter 17 Routine
Health Exam
93
94
95
96
Hypertension
Pulmonary hypertension,
secondary; Obstructive sleep
apnea
Gestational Diabetes Mellitus
Bladder Cancer
Chapter 18 Miscellaneous Internal Medicine Cases
97
98
99
100
101
Hyperthyroidism
Transient Ischemic Attack
Acute Renal Failure
Atrial Fibrillation
Neutropenic Fever
Chapter 19 Vaginal
Bleeding
102
103
104
105
Dysfunctional Uterine Bleeding
Von Willebrand Disease
Cervical Cancer
Endometrial Cancer
Chapter 20 Vaginal
Discharge
106
107
108
Bacterial Vaginosis
Candida Vulvovaginitis
Trichomoniasis
295
CCS CASES LISTED BY CASE NUMBER AND ALPHABETICALLY
Chapter 21
­Miscellaneous
­Obstetrics/­Gynecology
Cases
109
110
111
112
113
Urinary Tract Infection/
Pregnancy
Fibroadenoma
Breast Cancer
Polycystic Ovary Disease
Vulvar Carcinoma
Chapter 23
­Miscellaneous
­Pediatric Cases
117
118
119
120
Turner Syndrome
Glucose-6-Phosphate
Dehydrogenase Deficiency
Down Syndrome; Duodenal
atresia
Nephrotic Syndrome
Chapter 22 Pediatric
Fever
114
115
116
Erythema Infectiosum (Fifth
Disease)
Meningococcal Meningitis
Otitis Media
Alphabetical Case List
Final Diagnosis
Abdominal Aortic Aneurysm,
Ruptured
Acetaminophen Overdose
Acute Appendicitis
Acute Diverticulitis
Acute Lymphoblastic Leukemia
Acute Pancreatitis
Acute Pericarditis
Acute Renal Failure
Acute Sinusitis
Adult Polycystic Kidney Disease
Alzheimer’s Dementia
Anaphylaxis
Anorexia Nervosa
Aortic Dissection
Aortic Stenosis
Asthma
Atrial Fibrillation
Bacterial Vaginosis
Benzodiazepine Overdose
Bladder Cancer
Breast Cancer
Bronchiolitis
Candida Vulvovaginitis
Cardiac Tamponade
Case Number
77
49
8
21
34
9
35
99
86
16
42
66
28
3
73
4
100
106
41
96
111
68
107
64
Cervical Cancer
Child Abuse
Chronic Obstructive Pulmonary
Disease (COPD)
Colon Cancer/Iron Deficiency
Anemia
Complete Heart Block
(Third-Degree Atrioventricular)
Congestive Heart Failure
Crohn’s Disease
Croup
(Laryngotracheobronchitis)
Cystic Fibrosis
Deep Vein Thrombosis (DVT)
Depression
Diabetes Mellitus
Diabetic Ketoacidosis with
Sepsis
Dilated Cardiomyopathy
Down Syndrome; Duodenal
atresia
Dysfunctional Uterine Bleeding
Eclampsia with Fetal Distress
Ectopic Pregnancy
Elder Abuse
Endometrial Cancer
Erythema Infectiosum
(Fifth Disease)
104
51
74
23
65
70
80
63
82
54
88
25
5
69
119
102
6
11
91
105
114
296
Femoral Neck Fracture
Fibroadenoma
Foreign Body Aspiration
Gastric Cancer
Gastritis
Gastroesophageal Reflux
Disease/Barrett’s Esophagus
Gestational Diabetes
Mellitus
Giardiasis
Glucose-6-Phosphate
Dehydrogenase Deficiency
Gout
Hemophilia
Hepatic Encephalopathy
Herpes Zoster (Shingles)
Hodgkin Lymphoma
Hyperosmolar Hyperglycemic
State
Hypertension
Hypertensive Emergency
Hyperthyroidism
Hypothyroidism
Immune Thrombocytopenic
Purpura (ITP)
Infective Endocarditis
Intussusception
Irritable Bowel Syndrome
Laryngeal Cancer
Lead Poisoning/Iron Deficiency
Anemia
Lung Cancer
Meningococcal Meningitis
Mesenteric Ischemia
Multiple Sclerosis
Myocardial Infarction
Nephrotic Syndrome
Neutropenic Fever
Opioid Toxicity
Osteoarthritis
Osteoporosis/Vertebral Fracture
Otitis Media
Ovarian Cancer
Pancreatic Cancer
Panic Attack
APPENDIX
53
110
57
33
30
12
95
84
118
52
92
47
87
61
45
93
89
97
24
90
71
13
81
62
26
58
115
22
50
67
120
101
46
79
76
116
17
27
36
Parkinson’s Disease
Pelvic Inflammatory Disease
Peptic Ulcer Disease
Peptic Ulcer Disease with
Perforation
Pneumocystis carinii Pneumonia/AIDS
Pneumonia
Polycystic Ovary Disease
Pulmonary hypertension,
secondary; Obstructive sleep
apnea
Prostate Cancer
Prostatitis, Acute Bacterial
Pulmonary Embolism
Renal Cell Carcinoma
Rheumatoid Arthritis
Septic Arthritis
Sickle Cell Anemia with
Vaso-Occlusive Crisis
Sigmoid Volvulus
Small Bowel Obstruction
Splenic Hematoma
Spousal Abuse
Stable Angina
Subarachnoid Hemorrhage
Systemic Lupus Erythematosus
Temporal Arteritis/
Polymyalgia Rheumatica
Tension Pneumothorax
Thrombotic Thrombocytopenic
Purpura (TTP)
Toxic Shock Syndrome
Transient Ischemic Attack
Trichomoniasis
Tricyclic Antidepressant
Overdose
Tuberculosis
Turner Syndrome
Ulcerative Colitis
Urinary Tract Infection/
Pregnancy
Vitamin B12/Folate Deficiency
Von Willebrand Disease
Vulvar Carcinoma
44
18
31
19
59
7
112
94
75
78
72
29
2
56
10
14
15
20
55
38
40
37
85
1
48
43
98
108
39
60
117
83
109
32
103
113