Cases and Instructions

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The Frugal Diagnostician
Facilitator Instructions:
Divide the group into 2-4 teams. Provide each team with identical patient. Each team discusses the case
and can order a round of tests each “day”, during up to 3 “days” of hospitalization. For each test the
team orders on a particular day, the facilitator will provide the team with the charge for each test and
test result. This information is to be shared prior to decision-making and orders for the “next hospital
day”.
Each day of hospitalization also incurs a room charge. If a team feels they have reached a diagnosis
prior to day 3, they may discharge the patient to prevent additional hospital charges.
The goal is to correctly diagnose the patient in the most cost efficient manner. Thus, the team that
arrived at the diagnosis with the lowest bill (by adding up their charges) wins.
Charges should be obtained from the chargemaster of the trainee’s hospital.
The Frugal Diagnostician #1
Your task is to correctly diagnose the patient in the most cost effective manner. Please read the history
and physical below. Then, make a list of laboratory/imaging tests you would like to order. The test
results will be given to you along with a charge for one night in the hospital. At that point, you can
submit a diagnosis and discharge your patient, or keep them in the hospital another night and order
more testing. After 3 nights in the hospital, the patient must be discharged and a diagnosis submitted.
Upon discharge, your patient’s total bill will be calculated. The team that correctly diagnoses the
patient with the lowest bill, will be crowned the frugal diagnostician.
History of Present Illness:
52 year old man presents to the Emergency Department with chest pain and shortness of breath.
Symptoms have been present for approximately 1 hour. The pain was described to be in the middle of
his chest, and was acute in onset. Shortness of breath is worse with exertion, and he also notes a new
cough.
Past Medical History:
Hypertension
Obese
Low back pain
Family History:
Mother – Systemic Lupus Erythematous
Father – Diabetes Mellitus II
Physical Exam:
T 98.4 BP 156/87 P 84 R22 O2 91%
Gen: WD, WN, WM
HEENT: PERRL, EOMI
Chest: CTA B
CV: RRR No MRGs
Abd: BS+, soft, NT, ND
EXT: NO C/C/E DP2+
Neuro: CN II-XII intact, strength 5/5, DTRs NL
Social History:
1ppd smoker x 30 years
Occasional alcohol use
No illicit drug use
Monogamous with wife of 25 years
Employed as a truck driver
Medications:
Hydrochlorothiazide 25 mg daily
For Facilitator Use Only:
Case #1:
Diagnosis: Pulmonary Embolism
Cardiac Enzymes: CK, CK-MB normal. Troponin 0.1
All labs and tests are “within the normal range” except:
Electrocardiogram – sinus tachycardia
D-Dimer – 500 ng/mL
Lipid Profile – Total Cholesterol 200, LDL 170, HDL 25, Triglycerides 180
Lower Extremity Ultrasound – thrombus seen in the right femoral vein
V/Q scan – high probability
CT Chest with contrast – nonocclusive pulmonary embolus in the right pulmonary artery
The Frugal Diagnostician Case #2
Your task is to correctly diagnose the patient in the most cost effective manner. Please read the history
and physical below. Then, make a list of laboratory/imaging tests you would like to order. The test
results will be given to you along with a charge for one night in the hospital. At that point, you can
submit a diagnosis and discharge your patient, or keep them in the hospital another night and order
more testing. After 3 nights in the hospital, the patient must be discharged and a diagnosis submitted.
Upon discharge, your patient’s total bill will be calculated. The team that correctly diagnoses the
patient with the lowest bill will be crowned the frugal diagnostician.
History of Present Illness:
A 58 year old woman presents to the emergency room with lower extremity edema. Over the past 3-4
weeks she's noticed an abrupt increase in lower extremity edema and abdominal swelling. She's also
noticed weight gain although she is unable to quantify exactly how much weight she gained. Over the
same time period, she has noticed a decrease in urine output. She denies any current dyspnea on
exertion or shortness of breath at rest. She denies any fatigue, or bleeding. She really states that overall
she feels very well without fatigue, tiredness, abdominal pain, nausea, vomiting or any other significant
problems other than her swelling in her abdomen and her legs.
Past Medical History:
Hypertension
Medications:
Micardis/HCTZ
Aspirin 81mg daily
Social History:
She is married and works as a teacher at a
preschool. She states that she drinks socially
approximately one to 2 drinks 2 times per week
and has no history of heavy alcohol intake. She
smokes approximately 5-6 cigarettes per day
and has a 20-pack-year history of smoking. She
denies any history of illicit drug use.
Family History:
Her father died from heart disease in his late
60s. Her mother had diabetes mellitus and died
in her 60s
Physical Exam:
Temp 98.5 HR 88 RR20 BP 105/72 Oxygen 96%
Gen:African American female in no acute
distress.
Eyes: EOMI, PERRL
Nose, Mouth, Throat: moist oral mucosa, no
erythema, no lesions, no nasal deformities
Respiratory: Clear to auscultation bilaterally
Cardiacvascular: regular rate and rhythm, no
murmurs, rubs or gallops
GI: BS+, soft, NT, distended abdomen with
shifting dullness
Ext: No clubbing, cyanosis, DP 2+, 2+ pitting
edema to thighs bilaterally
Neuro: No focal neuro deficits, normal gait,
MAEW
Psych: Pleasant, appropriate, normal affect
Skin: No prominent rashes, no tattoos
US Abdomen:
Conclusion:
1. Enlarged, diffusely heterogeneous liver with innumerable solid lesions throughout both lobes. These are highly
suspicious for hepatocellular carcinoma.
2. Reversed flow demonstrated within the main and right portal veins, suggestive of portal hypertension.
3. Large ascites.
CT Triple Phase Abdomen
Impression:
1. Innumerable hepatic masses which show enhancement characteristics compatible with diffuse multifocal
hepatocellular carcinoma. Probable tumor thrombus within the right portal vein and multiple branches.
2. Hepatic artery-portal venous shunt, likely related to intratumoral shunt from the dominant right hepatic lobe
mass.
3. Findings of cirrhosis and portal hypertension with large volume of ascites.
MRI Abdomen:
1. Multifocal hepatic masses likely hepatocellular carcinoma.
2. Cirrhosis and portal venous hypertension.
Diagnosis: Cirrhosis (from Hepatitis C with Hepatocellular Carcinoma)
The Frugal Diagnostician Case #3
Your task is to correctly diagnose the patient in the most cost effective manner. Please read the history
and physical below. Then, make a list of laboratory/imaging tests you would like to order. The test
results will be given to you along with a charge for one night in the hospital. At that point, you can
submit a diagnosis and discharge your patient, or keep them in the hospital another night and order
more testing. After 3 nights in the hospital, the patient must be discharged and a diagnosis submitted.
Upon discharge, your patient’s total bill will be calculated. The team that correctly diagnoses the
patient with the lowest bill, will be crowned the frugal diagnostician.
History of Present Illness
A 29 year old white man presents to the emergency room with a 2 week history of abdominal pain,
nausea/vomiting, and hematuria. He first noticed red urine on his first void of the day 2 weeks ago. He
had run several miles the day prior. On subsequent voids, the redness faded and resolved, but he then
noticed fatigue. Then, one week ago he developed epigastric abdominal pain, lower back pain, nausea,
subjective fever/chills, and dark urine. He presented to an outside physician and was diagnosed with a
urinary tract infection. He was treated with ceftriaxone and ciprofloxacin but his symptoms persisted so
he presented the ER. He has no history of similar symptoms.
Past Medical History:
Allergic Rhinitis
Past Surgical History: None
Allergies: NKDA
Medications:
Fexofenadine
Ciprofloxacin
Social History:
He works as a private pilot. No recent sexual activity. No tobacco, alcohol, or illicit drug use.
Family History:
Both parents and all siblings are alive and healthy
Physical Exam:
T 98.4 BP 156/87 P 84 R16 O2 100% Wt: 170lbs
Gen: WD, WN, WM in NAD
HEENT: PERRL, EOMI, mild scleral icterus
Neck: No LAD or TM
Chest: CTA B
CV: RRR No MRGs
Abd: BS+, soft, NT, ND
EXT: NO C/C/E DP2+
Neuro: CN II-XII intact, strength 5/5, DTRs NL
The Frugal Diagnostician Case #3 Preceptor
Laboratory/Imaging Results:
133 / 99 / 34
-------------------155
3.4 /
20 /
7.9
5.2
3.4
\-------/ 91
22.4
Ca:8.7
mcv:100
lipase: 83
CT Abd/Pelvis: No adenopathy
PT:11 PTT:25.3
Lactate: 1.3
Spleen is upper limits of normal
TP 7.8 AST 102
Alk phos: 72
Otherwise normal CT abdomen
Alb 4.4 ALT 37
T bili 1.9
CT Chest: normal
D bili: 0.3
Urinalysis:
CK: 233
Spec grav: 1.030
LDH: 2642
Protein: 2+
Retic: 5.92%
Glu: 1+
ESR: 61
Blood:3+
Haptoglobin <1
Nitrate and LE: neg
B12, Folate, iron studies:
WBC: 3-5
normal
RBC: 0-2
All other tests not listed here are “normal”
RBCs positive for CD59 consistent with: Paroxysmal Nocturnal Hemoglobinuria (PNH)
The Frugal Diagnostician
Test Ordered
Result
Charge
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