USMLE Step 3 CCS and COMLEX Level 3 CDM is intended to help residents for their final exam of USMLE and COMLEX. Educating and preparing students and residents who are interested in the medical field.
Table Of Contents
USMLE Step 3 CCS and COMLEX Level 3 CDM
Acute Appendicitis
- – Emergency orders:
Answer
- none
- – PE:
- general, skin, HEENT/Neck, Chest/lung, cardiovascular, abdominal, genital, rectal, extremities/spine
- notable for:
- RLQ tender to palpation
- palpation of LLQ worsens RLQ pain
- – Location:
- transfer to ER
- – Order:
Answer
- All Stat
- IV access
- IV NSS 0.9%
- CBC with diff, BMP, LFTs, FOBT, UA
- abdominal US
- abdominal XR
- NPO
- PT/INR/PTT
- morphine IV continuous
- Phenergan IV continuous
- – Clock:
- advance to see results of u/s
- Results: leukocytosis, fecalith and inflamed appendix
- – Order:
Answer
- Cefoxitin IV one-time (pre-op abs)
- General surgery consult
- – Clock:
- advance clock to obtain surgeon’s recs
- – Order:
Answer
- lap appendectomy
- – Location:
- admit to ward
- – Clock:
- advance to next available result, appy is performed. reevaluate in 4-8 hours, then case ends
- – Final orders:
Answer
- cancel NPO and IV access
- order normal diet
- counsel parent and patient
Acute Diverticulitis
Case: 67 Yo M presents to ED c/o LLQ abdominal pain, fever, n/v. Hx of chronic constipation x10 years, HTN, hypercholesterolemia. Meds include HCTZ, simvastatin, & ASA. Vitals reveal a temp of 100.6 and are otherwise normal.
- – Emergency orders:
Answer
- none
- – PE:
- – Order:
Answer
- All STAT
- CBC w/ diff, BMP
- blood cx
- UA, AXR, abd CT
- IV access
- NPO
- – Order:
Answer
- NS (IV, cont)
- Ampicillin-sulbactam (IV, cont)
- Morphine (IV, cont)
- Phenergan (IV, cont)
- – Advance clock:
- to get CT results, note leukocytosis
- – Change location to:
- ward
- – Order:
Answer
- bed rest w/ bathroom privileges
- SCDs
- – Advance clock to:
- reevaluate q 12-24hrs until clinical improvement noted
- – Cancel:
Answer
- NPO
- vitals
- IV and infusions
- – Order:
Answer
- Percocet (PO, cont)
- Flagyl (PO, cont) and cipro (PO, cont)
- Advance diet
- Counsel high fiber diet, med compliance, med S/Es, regular exercise
- – Send patient home:
- w/ follow up 2-6 weeks
- – Final orders:
- none
Acute Gout
- – Emergency orders:
Answer
- None
- – PE:
- erythematous, tender, swollen R first metatarsophalangeal joint with limited ROM
- – Order:
Answer
- CBC, BMP, PT/INR, PTT, ESR, CRP, serum uric acid
- X-ray of toe
- Arthrocentesis with synovial fluid analysis (cell count and diff, gram stain, culture and sensitivity, viscosity, microscopy)
- – Order:
Answer
- Indomethacin PO continuous
- Counseling (avoid asa, avoid diuretics, avoid excessive amounts and alcohol and purine-rich foods, weight loss through diet and exercise, medication compliance, no smoking)
- – Location:
- change to “home”, schedule f/u appt in 1-2 weeks
- note results of the synovial fluid analysis: WBC count of 10,000 with 57% neutrophils, normal glucose, decreased viscosity, needle-shaped, negatively birefringent monosodium urate crystals.
- Patient improves. Case ends.
- – Final orders:
- none
Acute Pericarditis
- – Emergency orders:
Answer
- IV access
- pulse ox – 98%
- O2, cardiac monitor, BP monitor
- EKG – diffuse ST elevation
- – PE:
- cardiac – note pericardial friction rub
- – Order:
Answer
- CBC, BMP,CKMB and trop I, ESR
- Blood cultures
- CXR
- Ibuprofen PO continuous, colchicine PO continuous
- – Clock:
- advance to see results, ESR elevated, CBC shows lymphocytosis, cardiac enzymes reveal elevated CK with normal troponin.
- – Location:
- change to ward
- – Order:
Answer
- General diet
- Echo routine
- IV NS
- Ambulate at will
- Reassurance
- – Clock:
- advance to see echo result – pericardial effusion but no tamponade
- – Clock:
- advance until symptoms improve
- – Order:
Answer
- Patient counseling
- d/c inpatient orders
- – Location:
- change to “home”, schedule f/u appt in 2 weeks, case ends
- – Final orders:
- none
Acute renal failure
- – Immediate orders:
Answer
- None
- – Exam:
- Complete
- – Initial orders:
Answer
- Pulse ox, O2, IV
- IV NS bolus
- gtt
- Foley
- EKG,
- ABG
- CBC, Mg, BMP
- UA, UCx and sens
- UNa, UCr -> results show pre-renal failure 2/2 dehydration, admit pt to floor
- – Admit orders:
Answer
- D/c lisinopril and ibuprofen
- Continue home meds
- VS q2h
- 24 urine protein
- diabetic and renal diet
- bed rest
- renal US
- daily weights, strict I/Os
- accu checks QID
- HbA1c
- SSI -> pt status improves
- – Final orders:
Answer
- d/c bed rest OOB
- d/c foley
- cont diet, PO fluids
- freq electrolyte monitoring
- – Counseling:
- Med compliance, dietician, seat belts
Alcohol withdrawal
- – STAT:
Answer
- None
- – PE:
- Gen, CV, lungs, HEENT, neuro, abd, ext -> do emergency care as pt has DT
- – Emergency orders:
Answer
- Pulse ox, O2, cardiac monitor, IV
- IV NS bolus and continuous
- blood glucose
- NPO
- EKG
- IM thiamine, PO folic acid, IV lorazepam
- soft restraints
- aspiration precautions
- – Initial orders:
Answer
- CBC, BMP, LFTs, coags, Mg, Phos
- Blood Cultures
- ABGs
- urine tox
- BAL
- CXA, CT head
- LP if suspect meningitis
- – Orders after results:
Answer
- IV 50% glucose after thiamine, MV, PO folate
- IV lorazepam -> admit to ICU for withdrawal management
- – Admit orders:
Answer
- cont IV lorazepam
- Haldol for agitation
- IV ND, IV MV with folic acid
- replete electrolytes
- vit K if PT/INR elevated
- H&P q1-2 hours
- – Final orders:
Answer
- When stable d/c IV lorazepam and start Librium protocol
- – Counseling:
Answer
- Rehab, AA
- safe sex, limit alcohol, no smoking, drive with seat belt, safety plan
Angina
- Stable Angina:
- Work up:
Answer
- EKG
- EKG stress test
- Management:
Answer
- Aspirin – decrease the progression
- BB
- Nitro – symptom relief and afterload reduction
- Statin
- Smoking Cessation
- Unstable Angina:
- Workup/Management:
Answer
- Aspirin
- BB
- Nitro
- Heparin (anticoagulation)
- PCI – for definitive tx with revascularization
- Conditional:
- oxygen only to keep sats above 90
- high dose atorvastatin asap, but before above medications
- morphine – persistent distressing pain
- Conditional:
Asthma Exacerbation
Case: 32M w/ hx of asthma presents to the ED with shortness of breath, wheezing, and cough. Last asthma exacerbation was 1 year ago, he has never been hospitalized for asthma, + smoker. + Tachypneic and tachycardia.
- – Emergency orders:
Answer
- pulse ox- 90% on room air, o2
- IV access
- head elevation
- cardiac monitor
- – PE:
- General, HEENT, chest/lungs, heart, abdomen, extremities
- moderate respiratory distress, accessory muscle use, inspiratory and expiratory wheezes, hyper-resonance, equal air entry bilaterally, tachycardia
- – Order:
Answer
- Peak expiratory flow rate
- ABG
- CXR, CBC, BMP
- EKG – 12 lead
- albuterol nebulized continuous, methylpred IV continuous
- – Clock:
- advance 45 minutes for interval f/u and general/lung exam, pt still in respiratory distress
- – Order:
Answer
- ipratropium bromide nebulizer continuous
- – Clock:
- advance every hour for 3 hours for interval f/u, general/lung exam and repeat PEFR, pt not improving.
- – Location:
- change to “ward”
- – Order:
Answer
- albuterol nebulized continuous, methylprednisolone IV continuous
- NPO
- complete bedrest
- normal saline
- peak flow q2hrs
- – Clock:
- reevaluate q2-4 hours for 24 hours interval f/u, see pt improving
- – Location:
- change to “home”
- – Final orders:
Answer
- counseling – smoking cessation and asthma care
- cancel NPO
- start normal diet
- complete bed rest
- cardiac monitor
- ambulate at will
Bronchiolitis
Case: 6-month-old male is brought to the clinic by his mother with a runny nose, noisy breathing, low-grade fever, emesis containing mucus, and poor feeding. The boy has older siblings who have had a “cold” in the past week. The boy is healthy, vaccines UTD. Low-grade fever and tachypnea.
- – Emergency orders:
Answer
- pulse ox – 91% on room air, o2
- – PE:
- good hydration status, edematous nasal mucosa, profuse clear rhinorrhea, nasal flaring, mild subcostal retractions, hyperinflated lungs, b/l diffuse expiratory wheezing and rhonchi
- – Location:
- change to ER
- – Order:
Answer
- CBC, BMP
- CXR
- ABG
- UA/ucx
- acetaminophen rectal one time, albuterol nebulized continuous
- IVF
- naso-tracheal suctioning
- IV access, cardiac monitor
- – Clock:
- advance to see results – leukocytosis with lymphocyte predominance, hyperinflated lungs, pO2 61
- – Clock:
- advance 1 hour, no improvement
- – Order:
Answer
- epi inhalation one time
- – Clock:
- advance clock one hour to reevaluate the patient, the patient improved
- – Location:
- change to “ward”
- – Order:
- change frequency of pulse ox to q8hrs
- – Clock:
- advance q8hrs until pt has been there for 24 hours, pt remains stable
- – Order:
Answer
- cancel all inpatient orders
- parent counseling
- – Location:
- change to home, schedule an appt in 1-2 weeks, case ends
- – Final orders:
- none
Cellulitis
Case: 45y/o construction worker presents to the ED with pain and swelling of the RLE x 2 days, s/p work-related laceration. No discharge from the lac. Last tetanus 4 years ago. Febrile to 103.1 and tachycardia.
- – Emergency orders:
Answer
- IV access
- o2, pulse ox, cardiac monitor, BP monitor
- – PE:
- 2cm lac on the R shin that is very tender and surrounded by diffuse erythema and edema.
- – Order:
Answer
- CBC, BMP, LFTs, ESR, CRP, lactic acid
- blood cx’s
- Clindamycin IV
- X-ray RLE
- morphine IV continuous
- – Clock:
- advance to see results of everything but blood cx’s, note leukocytosis with left shift, soft tissue swelling of the R leg, mildly elevated ESR, neg blood cx’s
- – Location:
- change to “ward”
- – Order:
Answer
- IV NS
- bedrest with bathroom privileges
- leg elevation
- general diet
- PO analgesia, PO antipyretics
- daily CBC
- – Clock:
- continue to request interval hx and focused exam daily until improvement noted
- – Order:
Answer
- cancel inpatient orders
- start clindamycin oral continuous
- provide counseling (medication compliance)
- – Location:
- send patient home
- – Clock:
- schedule a f/u appt in 1-2 weeks, case ends
- – Final orders:
- none
CHF exacerbation in diabetic
- – Immediate orders:
Answer
- Elevate Head of Bed
- pulse ox, O2, IV access, cardiac monitor
- EKG
- – Exam:
- Gen, HEENT, CV, lungs, abd, ext
- – Initial orders:
Answer
- IV lasix
- CXR
- CBC, BNP, CE stat and q8 x2 -> admit to floor
- – Admit orders:
Answer
- Tele, AAT
- low salt/cholesterol/diabetic diet, fluid restriction, UOP
- daily weight
- compression stockings
- cont home meds
- EKG, BMP, HbA1C, lipid profile
- accucheck,
- KCl with lasix, dig
- echo
- – Heart failure meds:
- ASA, dig, BB, ACE-I, diuretic
- – Orders after results:
Answer
- Interval hx and focused exam
- NPH and regular insulin, simvastatin
- convert IV to PO medication
- wean O2
- – Final orders:
- F/u in 2 weeks
- – Counseling:
Answer
- Pt education
- cardiac rehab, no smoking, no alcohol, regular exercise, med compliance, seat belt use
Child Abuse
- – Emergency orders:
Answer
None
- – PE:
- Full PE
- – Order:
Answer
- All STAT
- pulse ox
- CBC w/ diff, PT/PTT/INR, bleeding time
- CXR
- – Advance clock to:
- obtain test results (note rib fx)
- – Order:
Answer
- ibuprofen (PO, cont)
- chest PT (stat)
- reg diet
- CPS consult (stat)
- psych consult (routine)
- parent counseling
- – Admit patient to:
- ward
- – Advance clock to:
- get CPS recommendations, reeval in 12-24 hrs
- – Final orders:
- none
Colon Cancer
- – Emergency orders:
Answer
- None
- – PE:
- full PE
- – Order:
Answer
- CBC w/ diff, BMP, LFTs, ESR, TSH
- FOBT
- colonoscopy (routine)
- polyethylene glycol (PO, once)
- – Send patient home:
- w/ f/u in 1-2 weeks
- – On return:
- request interval hx & do focused PE
- – Admit patient to:
- ward
- – Order:
Answer
- abd CT, CXR
- CEA
- UA
- EKG
- PT/PTT/INR
- oncology consult, surgery consult
- counsel (cancer dx)
- iron sulfate (PO, cont)
- – Advance clock to get results
- – Order:
Answer
- NPO, IV access, NS
- flagyl (IV, once), cipro (IV, once)
- hemicolectomy
- – Advance clock to get result
- – Reevaluate q12-24hrs & request interval f/u until patient ready for d/c
- – Order:
Answer
- pain meds if needed
- – Final orders:
Answer
- cancel NPO, order reg diet
- no smoking, no alcohol
COPD Exacerbation
Case: 63M w/ hx of smoking and COPD presents to the ED with progressively worsening SOB and wheezing. + worsening cough productive of yellow sputum. Vital signs stable. + one previous hospitalization for COPD exacerbation, medication = inhaled albuterol.
- – Emergency orders:
Answer
- elevate head of bed
- cardiac monitor, pulse ox, oxygen, IV access
- – PE:
- moderate resp distress, accessory muscle use, inc AP chest diameter, dec breath sounds, diffuse rhonchi and wheezing, prolonged expiration.
- No peripheral edema, no JVD.
- – Orders:
Answer
- PEFR q1hr
- CXR – PA and lateral
- ABG
- EKG
- CBC, BMP
- albuterol nebulizer – continuous.
- ALL STAT
- (if you’re in the ED, it’s stat!)
- – Clock:
- advance by 30 minutes – see low PEFR, low o2 sat, abnormal CXR
- – Order:
Answer
- ipratropium nebs
- IV methylprednisolone
- oral or IV abx (if oral – bactrim or doxy; if IV – levofloxacin, moxifloxacin, ceftriaxone, cefotaxime)
- – Clock:
- advance by 4 hours, pt improves
- – Location:
- transfer to “ward”
- – Orders:
Answer
- as pt improves, convert steroids from IV to PO
- convert albuterol and ipratropium from nebs to MDI
- if PaO2 55 or SaO2 88% –> d/c on home O2
- – Final orders:
Answer
- Counseling – smoking cessation, flu vaccine, pneumococcal vaccine
Cystic Fibrosis
- – Immediate orders:
- None
- – Exam:
- Complete -> admit to ward b/c doesn’t look good
- – Admit orders:
Answer
- Pulse ox, O2, IV
- sputum GS, C&S, BCx, CBC, BMP
- CXR, sinus XR
- sweat chloride
- 72-hour fecal fat
- – Initial orders:
Answer
- Augmentin
- albuterol nebs, MV
- chest PT
- vitals q6, D5NS
- reg diet, AAT -> Fecal fat elevated, Cx grew MSSA
- – Orders after results:
Answer
- D/c augmentin and fluids, start cephalexin
- flu shot, pneumococcal vaccine
- consult dietitian
- panc enzymes
- – Final orders:
- F/u in 2-3 mo.s
- – Counseling:
Answer
- Genetic
Dermatitis herpetiformis
DKA
- – STAT:
Answer
- None
- – PE:
- Gen, HEENT, CV, chest, abd ext
- – Initial orders:
Answer
- pulse ox, O2, IV, IV NS, cardiac monitor
- finger stick glucose, bHCG, CBC, BMP, EKG, amylase, lipase
- UA
- ABG
- serum osm/ketones
- IV insulin and phenergan -> admit to ICU
- – Admit orders:
Answer
- NPO, bed rest, VS, UOP
- IV KCl, HbA1C, phos level, BMP q2-4 hr
- ABG q2 hr x2
- – Orders after results:
Answer
- Stop NS and give 1/2 NS after 4 hrs
- add K as needed
- d/c IV insulin, fluids and heart monitor and go with NPH, regular insulin, diabetic diet
- – Final orders:
- F/u in 10 days
- – Counseling:
Answer
- Diabetic teaching, education, foot care, home glucose monitoring
- no alcohol, no smoking, safe sex, no drugs
- regular exercise, seat belts
expand]
DVT
Case: 48M truck driver presents w/3-day hx of increasing pain & swelling of RLE. Denies trauma and has no PMH. Smokes 1-2ppd, job entails long periods of immobility. Vitals reveal low-grade fever and are otherwise normal.
- – Emergency orders:
Answer
- none
- – PE:
- focused
- – Transfer patient to:
- ED
- – Order:
Answer
- LE doppler US
- CBC, BMP, D-dimer (all as STAT)
- – Advance clock to:
- get results
- – Order:
Answer
Hidden content goes here
- – Advance clock to:
- get results
- – Order:
Answer
- enoxaparin (SC, cont), warfarin (PO, cont)
- percocet (PO, cont)
- counsel (med compliance, med SEs, no smoking)
- – Send patient home:
- w/ f/u next day
- Daily interval f/u, focused exam, PT/INR until therapeutic, repeat CBC on day 3
- – Final orders:
- none
Gastroenteritis
- – Immediate orders:
Answer
- None
- – Exam:
- Complete
- – Initial orders:
Answer
- IV access, IV NS bolus and continuous
- CBC, BMP
- UA
- stool heme/leukocytes/cx
- breastfeeding ad-lib -> admit to floor b/c dehydrated
- – Admit orders:
Answer
- IV K, VS q4h, daily BMP
- repeat exam and hx q4-6 hrs
- – Orders after results:
Answer
- D/c to home when pt hydrated and BMP is nl
- – Final orders:
- F/u in 2 weeks
- – Counseling:
Answer
- Nutrition
G6PD Deficiency
- – Immediate orders:
Answer
- None
- – Exam:
- Complete
- – Initial orders:
Answer
- CBC, BMP, LFTs, prothrombin -> admit to floor
- – Admit orders:
Answer
- IV, IV NS
- reg diet
- AAT, retic count, Ca retic production index, serum haptoglobin, LDH
- UA
- type and cross, set up PRBC
- – Orders after results:
Answer
- Repeat H&H in 12 hrs, G6PD blood, Coomb’s test
- – Final orders:
- Appt in 2 mos, reassurance
- – Counseling:
Answer
- Limit alcohol use,
- reg exercise
- safe sex
Hypertensive Emergency/Urgency
Case: 48M w/ hx of HTN and non-compliance with medications presents to the ED with nausea, vomiting, blurred vision, and headache, found to have BP of 240/150. No chest pain, no focal neuro deficits. + 28 pack-year smoking hx.
- – Emergency orders:
Answer
IV access, oxygen, pulse ox, cardiac monitor, BP monitor
- – PE:
- general, HEENT/neck, chest/lung, CV, abdominal, ext/spine, neuro/psych
- – Order:
- Answer“stat” – 12-lead EKG, head CT, CBC, BMP, UA, CXR-PA
- Answer
- – Clock:
- advance clock to see head CT results will see all lab results – BUN/creat elevated; CT neg for hemorrhage; LVH on EKG
- – Order:
Answer
Nitroprusside, IV, continuous; arterial line
(first-line – IV nitroprusside)
(alternatives – IV labetalol, IV nicardipine) [/expand]
- – Location:
- change to “ICU”
- – Order:
Answer
- NPO
- complete bed rest
- monitor urine output
- – Clock:
- advance 15 minutes to reevaluate the patient; see that BP has improved
- – Clock:
- advance clock to check BP every 30-60min until BP is under control and pt is sx-free
- Goal:
- – Location:
- once a 25% drop in BP is achieved, transfer to “ward”, d/c arterial line, change to PO anti-hypertensive
- – Location:
- change to “home”
- – Final orders:
Answer
- lipid profile, routine
- counseling (medication compliance, smoking cessation, exercise, limit alcohol intake, low salt diet)
Hyperthyroidism
- -STAT:
Answer
- None
- – PE:
- Complete
- – Initial orders:
Answer
- CBC, BMP, EKG, TSH, free T3/T4, bHCG -> shows hyperthyroidism
- – Orders after results:
Answer
- 24-hr radioiodine uptake, when increased add propranolol, methimazole -> f/u in 4 wks
- – Final orders:
Answer
- at f/u CBC
- stop MMA
- do radioiodine, f/u in 1 mo
- – Counseling:
Answer
- Safe sex, no smoking, mild alcohol, seat belts
Lead poisoning
- – STAT:
Answer
- None
- -PE:
- Complete
- – Initial orders:
Answer
- Fingerstick lead, CBC, BMP, Ca level
- MoM, docusate
- UA -> appt in 3-5 days
- – Orders after results:
Answer
- Venous lead level that is between 45-75 -> Lead paint assay, increase Ca in diet
- iron/ferr/TIBC, LFTs and erythrocyte protoporphyrin followed by succimer therapy -> f/u in 1 month
- – Final orders:
Answer
- Repeat lead level, CBC, repeat erythrocyte protoporphyrin -> f/u in 4-6 wk.s with repeat erythrocyte protoporphyrin and blood lead, MV with iron and Ca in diet
- – Counseling:
Answer
- home safety
- diet high in Ca and iron
Lung cancer
- stat:
Answer
- Pulse ox, O2
- PE:
- Gen, HEENT, lungs, CV, abd, ext -> admit to floor when exam shows clubbing, osteoarthropathy, dyspnea, wt loss
- – Admit orders:
Answer
- O2, IV access, IV NS, UOP, VS q4h, pulse ox q4
- bed rest with bathroom
- CXR, BCx, sputum GS, cx
- cytology
- CBC, BMP
- Levaquin IV after cx
- alb/ipra nebs -> concerning for lung Ca
- – Initial orders:
Answer
- CT of chest, consult pulm for bronch
- CBC/BMP
- daily, cont O2 -> find SSC of lung
- – Orders after results:
Answer
- Normalize by IV to PO and nebs to MDI
- PFTs
- LFTs, serum Ca
- CT abd/pelvis, MRI brain, bone scan
- consult onc, consult rad onc
- – Final orders:
- F/u recs
- – Counseling:
Answer
- Stop smoking
- high protein diet supplementation
- Ca diagnosis
Narcotic overdose – pt unconscious
- – Immediate orders:
Answer
- Suction, pulse ox, O2, intubation if indicated
- ABG
- IV access, cardiac monito
- foley
- finger stick glucose
- thiamine, dextrose, naloxone
- NS
- – Exam:
- Gen, HEENT, CV, skin, chest, abd, ext, neuro
- – Initial orders:
Answer
- EKG, CBC, BMP, LFTs
- CXR
- UA, urine tox, bHCG
- BAL, NGT, activated charcoal, naloxone -> move to ICU
- – Admit orders:
Answer
- NPO
- bed rest
- UOP
- BMP daily
- – Orders after results:
Answer
- D/c O2, NGT, cardiac monitor, fluids, and naloxone
- give reg diet, maybe start antidepressant
- – Final orders:
Answer
Hidden content goes here
Psych consult stat for suicide attempt
- – Counseling:
Answer
- Suicide precautions, suicide contract, pt counseling, reassurance
- no alcohol, no smoking, safe sex, no illegal drugs
- regular exercise, seat belts
Osteoarthritis
Answer
Answer
Answer
PCOS
- – STAT:
Answer
- None
- – PE:
- Gen, HEENT, LN, lungs, CV, Abd, pelvic, ext, skin, neuro
- – Initial orders:
Answer
- bHCG, serum testosterone, DHEAS, prolactin, 24 hr cortisol, and 17-ketosteroids, TSH, LH, FSH
- pelvic US -> f/u in 1 week, PCOS diagnosed
- – Orders after results:
Answer
- Fasting lipids, glucose tolerance
- – Final orders:
Answer
- OCPs
- pap smear -> f/u in 1 wk
- – Counseling:
Answer
- low fat/calorie diet, wt reduction, regular exercise
Pulmonary Embolism
Case: 48Yo F overweight presents to ED w/ 1 day hx of pleuritic, left-side chest pain. Generally healthy and takes OCPs for menstrual abnormalities. Smokes 1ppd and has FHx of CAD. Vitals show tachypnea & borderline tachycardia.
- – Emergency orders:
Answer
- pulse ox, O2, IV access
- EKG, cardiac monitor
- (STAT)
- – PE:
- focused
- – Advance clock:
- for EKG
- – Order:
Answer
- CBC w/ diff, cardiac enzymes, D-dimer
- ABG
- pulse ox q2h
- CXR
- (STAT)
- – Advance clock:
- to get results
- – Cancel:
Answer
- OCPs
- – Order:
Answer
- PTT q6h, BMP
- spiral chest CT
- (STAT)
- – Order:
Answer
- heparin (IV, cont) or if Cr is normal, lovenox (SC, cont)
- – Advance clock:
- for CT result
- – Admit patient:
- to ward
- – Order:
Answer
- complete bed rest
- reg diet
- INR daily, CBC daily
- warfarin (PO, cont)
- – Reevaluate q24hrs:
Answer
- interval f/u & focused PE
- daily lab review for therapeutic INR
- monitor platelets
- – Cancel:
Answer
- O2, pulse ox, cardiac monitor, BP monitor
- – Final orders:
Answer
- counsel (no smoking, med compliance, med SEs)
Subarachnoid Hemorrhage
- -STAT:
Answer
- None
- PE:
- Gen, HEENT, lungs, CV, abd, CNS, ext
- – Initial orders:
Answer
- IV access, IV NS
- IV Toradol
- ESR
- CT head non-con -> admit to ICU after CT shows SAH
- – Admit orders:
Answer
- Cardiac monitor, pulse ox q2h
- NPO
- bed rest
- UOP, neuro checks q1h
- CBC, BMP, EKG, coags
- transcranial doppler
- NSGY consult
- Percocet, docusate, PO nimodipine, PPI
- compression stockings
- – Orders after results:
Answer
- Follow NSGY recs, likely angiogram
- – Final orders:
Answer
- Daily BMPs
- – Counseling:
Answer
- seat belts, safe sex
- no smoking, no alcohol
Pediatrics
Infant with jaundice in the hospital
- STAT:
Answer
- None
- PE:
- Complete
- – Initial orders:
Answer
- Blood type of infant and mother, direct coomb’s test, CRP stat q12h, CBC, total and indirect Br
- I/Os, VS q4h -> pt appears to be having ABO incompatibility
- – Orders after results:
Answer
- H&H q8h, Br q8h
- breast feeding, supplement with formula -> Br keeps going up, admit to NICU
- – Admit orders:
Answer
- Phototherapy
- erythromycin ointment,
- IV fluids
- – Final orders:
Answer
- D/c fluids and phototherapy when improved
- f/u Br until stable
- – Counseling:
Answer
- May take 2-3 wks for jaundice to resolve, breast milk, seat belts
Child intoxication
- – STAT:
Answer
- Pulse ox, O2, cardiorespiratory monitoring
- finger stick glucose, IV lock
- urine tox
- narcan
- – PE:
- Gen, HEENT, CV, lung, abd, msk, neuro -> glucose is 48, no change with narcan
- – Initial orders:
Answer
- 1 amp D50, IV NS
- BAL
- serum tox panel
- BMP, CBC, Mg, phos, q1h accuchecks -> BAL elevated so admit to floor
- – Admit orders:
Answer
- Continuous cardiorespiratory monitoring
- IV D5NS at maintenance
- NPO
- BMP in AM, BAL q12h, replete lytes -> pt more responsive and BAL nl
- – Orders after results:
Answer
- Screen for abuse and domestic violence
- – Final orders:
- D/c home, f/u in 2 wk.s
- – Counseling:
Answer
- Drug use, toxicity
Child with nephrotic s/d
- – STAT:
Answer
- None
- – PE:
- Complete
- – Initial orders:
Answer
- UA
- BMP, CBC, LFTs, lipid panel, coags, complement 3/4 levels -> pt unstable, admit to floor
- – Admit orders:
Answer
- I/Os, VS q4, cardioresp monitoring
- nephrology consult
- IV albumin, lasix, CMP qAM
- no salt high protein diet -> pt stable
- – Orders after results:
Answer
- Prednisone 2 mg/kg per day
- VS q12 hr.s, repeat albumin and lasix -> d/c to home
- – Final orders:
Answer
- Prednisone 4-6 wks, f/u in 3-5 days
- – Counseling:
Answer
- A healthy diet, exercise, may relapse
GBS pneumonia in a kid
- -STAT:
Answer
- Pulse ox, O2
- – PE:
- Gen, HEENT, CV, lung, abd, neuro, msk, skin
- – Initial orders:
Answer
- O2, IV access
- CBC, BMP, BCx, UCx
- CSF cx
- CXR
- CRP -> admit to floor as pt as PNA
- – Admit orders:
Answer
- Cardiorespiratory monitoring, VS q4
- NPO if RR>60
- IV D5 1/2NS
- IV amp, IV cefotaxime
- I/Os
- CBC/BMP daily -> BCx grows G+ cocci in chains
- – Orders after results:
Answer
- Eval q2-4 hrs, then q8-12 hrs
- reg diet when RR improved, wean O2 -> cx grows GBS sens to amoxicillin
- – Final orders:
Answer
- D/c home when stable, change abx to amoxicillin
- – Counseling:
Answer
- seat belts, healthy diet, exercise
Transient ischemic attack
- – Emergency orders:
Answer
- None
- – PE:
- general, CV, resp, neuo – loud bruit over L carotid.
- – Order:
Answer
- cbc, bmp, head CT – “stat”
- – Clock:
- advance to see above results;
- head CT is neg for hemorrhage
- – Order:
Answer
- ASA, continuous
- – Location:
- Change location to “ward”
- – Order:
Answer
- a diabetic diet
- ambulate at will
- glucometer glucose q8hr
- carotid doppler
- cardiac monitor, echo
- MRI head, MRA head
- HbA1c, lipid profile – all “stat”
- – Clock:
Answer
- advance to get carotid doppler results – > 70% L ICA stenosis; echo shows no thrombus.
- – Order:
Answer
- vascular surg consult – for CEA for >70% L carotid artery stenosis and TIA
- – Clock:
- advance to get consult recommendation
- – Order:
Answer
- cancel diabetic diet
- order pre-op (PT/INR, PTT, NPO, cefazolin – IV one-time
- CEA (carotid endarterectomy)
- – Clock:
- advance to get CEA result
- – Final orders:
Answer
- counseling (no smoking, no alcohol, regular exercise, diabetic diet, med compliance, better BP control, DM control)
Unstable Angina
- – Emergency orders:
Answer
- oxygen
- IV access, cardiac monitor, continuous BP monitor, pulse ox
- EKG – 12 lead
- asa, nitro – sublingual, one time – stat
- – PE:
- focused – general, HEENT/neck, chest/lung, cardiovascular, abdominal, genital, rectal, extremities/spine
- – Clock:
- advance to see EKG results – ST depressions and T wave inversion, no ST elevations
- – Order:
Answer
- rectal – FOBT
- metoprolol, IV, one time – to decrease HR to 60-70
- – Clock:
- advance to see FOBT results – negative
- – Order:
Answer
- heparin IV continuous
- PTT q6hrs, CBC with diff, BMP, LFTs, CK-MB and trop q8hrs
- portable CXR-PA
- PT/INR
- – Clock:
- advance to see enzymes – negative (suggesting unstable angina), interval f/u – partial relief from chest pain
- – Location:
- change to “ICU”
- – Order:
Answer
- consult cards – for unstable angina, catheterization.
- Order GP IIB/IIIA inhibitors – eptifibatide IV continuous
- NPO
- bedrest
- urine output
- metoprolol PO continuous, simvastatin PO continuous
- echo stat
- lipid panel
- – Clock:
- advance 1 hour to obtain consultant’s recommendations, interval f/u – pt’s chest pain resolved
- – Order:
Answer
- cardiac cath routine
- coronary angioplasty routine
- – Clock:
- advance to obtain procedure results
- – Final orders:
Answer
- counseling – pt counseling, smoking cessation, limit alcohol, exercise program, medication compliance, relaxation techniques, diet – low sodium, diet – low cholesterol
- order d/c meds: asa, metoprolol, statin, sublingual nitro, clopidogrel
- set up f/u appt in 2-6 weeks.
