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CCS cases 1-10 - Coggle Diagram
CCS cases 1-10
Acute renal failure/pre-renal azotemia
Complete physical exam
Pulse Ox, IV access, NS, Foley catheter, EKG, ABG, CBC with differential, Mg and Phosphate, BMP Q 8 hrs, UA, Urine culture and Urine sodium and creatinine
PT dehydrated: give fluids, if patient is volume overloaded= give diuretics
Determine pre-renal, renal and post-renal azotemia
If BUN=Normal and Cr= high (renal failure): give insulin for K, and check EKG, If patient taking nephrotoxic drugs like NSAIDS and ACE, stop them,
Order: Transfer to ward/floor, Vitals q2h, 24 hr urine protein, diabetic and renal diet, complete bed rest, Heparin 5000 Units S/C Q12hrs to prevent DVT, Renal U/S, daily weights, Strict input/output, Acu checks QID, HbA1C, sliding scale insulin
For pre-renal: increase flow by giving hydration, if that does not work, give furosemide, if HF is the cause give dobutamine and dopamine, give NaHCO3 when pt is extremely acidic
PT mental status improves: discontinue bed rest and foley catheter, from bed to chair, renal diet and alot of fluids,
Diabetic Ketoacidosis
Examine the whole patient
Order Stats: Pulse Ox (stat & Continuous), Oxygen inhalation (continuous), IV acces (stat), NS 0.9% continuous), finger stick glucose (stat)
Order: Urine pregnancy, stat. CBC with differential, BMP, Calcium serum, EKG 12 lead, Serum amylase, lipase, UA, ABG, Serum osmolality, Serum ketones, regular insulin IV, phenergen IV, discontinue oxygen
Review orders: admit patient in ICU, NPO, Bed rest, vitals as per ICU protocol, Urine output, KCl IV, cont, HbA1C, Phosphorus, serum stat, Follow the patient with BMP Q2-4 hrs, then Q 8-12 hrs then Q day and ABG Q 2 hours twice and after 4 hrs stop 0.9% NS and give 1/2 NS, IV, continuous. Monitor K and add KCl as needed, add antibiotics if the cause of DKA is infection, get CXR, blood cultures and urine cultures. when nausea decreased, start oral fluids,
Patient stabilizes so transfer to ward/floor
Discharge with D/C IV insulin , IV fluids, cardiac monitor, NPH insulin, S/C, cont, Regular insulin, S/C, cont, Diabetic Diet, Advance diet and counsel about diabetic education, patient education, diabetes, diabetic foot care, home glucose monitoring, no alcohol, no smoking, safe sex, no illegal drug use, regular exercise, seat belts use,
Follow-up in 10 days
Narcotic Overdose
As this is an emergency case, start with A= Airway suction, pulse ox, stat, cont, O2, B= Endotracheal intubation if patient ox stat do not improve, C= IV access, continuous cardiac monitor, place Foley, get finger stick glucose, D= drugs= give thiamine, dextrose 50% and naloxone, all one time.
Exam: Respiratory
1+ give NS 0.9% and ABG stat
PE: examine everything
Dx: EKG, CBC, BMP, CXR, LFT, UA, urine toxicology, B-HCG, Blood alcohol and initial tx: NG tube, gastric lavage, charcoal, naloxone
Move patient to ICU, NPO, Bed rest, Urine output, BMP once patient is better, D/C oxygen, NG tube, cardiac monitor, IV fluids, naloxone, regular diet,
Educate patient and family: psychiatry consult if suicidal attempt, suicide precautions, suicide contract, patient counselling, reassurance, no alcohol, no smoking, safe sex, no illegal drug use, regular exercise, seat belts use. Start pt on anti-depressant if needed.
Acute exacerbation of Heart Failure (systolic and diastolic)
Elevate the head of the bed, Pulse Ox, Oxygen, IV access, cardiac monitor, EKG-12 lead
Physical exam
CXR, CBC with differential, BMP, Troponin 1 Q6 hoursx2, LFT, NT-proBNP, Furosemide IV
Orders: Admit to ward, Telemetry, Ambulate at will, low salt, low cholesterol, diabetic diet, Fluid restriction, input/output monitor, daily weights, continue all meds except glyburide, KCL given with furosemide, insulin sliding scale, Accu check, give 10 units regular insulin now, levonox s/c daily for DVT prophylaxis, BMP (next day), Lipid profile, HbA1C, Echo
HOSPITAL DAY 2: Examine the patient, IV to oral, determine for discharge, assess for oxygen
AT DISCHARGE: Patient education, cardiac rehab program, no smoking, no alcohol, regular exercise, diet and medication compliance
Follow-up in a week
G6PD Deficiency (pt presents with jaundice)
Physical Exam
Routine Orders: CBC with differentials, BMP, LFTs, and prothrombin time, peripheral blood smear
Routine order review: Admit the patient in floor/ward, IV access, NS, Diet: regular and avoid fava beans, activity=ambulation at will, retic count and retic production index, haptoglobin, LDH, urinalysis, type and cros match, packed RBC transfusion.
Repeat Hb and Hematocrit in 12 hrs
G6PD blood and Coombs test. If G6PD is normal than you can repeat the test to confirm if you suspect G6PD
Schedule an appointment after 2 months and check G6PD assay, reassurance, pt counselling, limit alcohol, regular exercise and safe sex
Cystic Fibrosis
Physical Exam (without breasts)
Admit to ward, Pulse ox (every 4hrs), IV access, Sputum gram stain and sputum culture and sensitivity, Blood culture, CBC, BMP, CXR, Sinus Xray, Sweat Chloride, 72 hr fecal fat estimation
Treatment= oxygen cont, augmentin, nebulized Albuterol (4x), multivitamin tablets (fat-soluble vitamins and pancreatic enzymes) , chest physiotherapy, Vitals Q 6 hrs, D5NS (6hrs), Regular diet (high proteins and high calories) and ambulation at will
Follow-up for such patients every 2-3 months and provide prophylactic vaccinations of influenza, measles and pertussis
Inhaled Glucocorticoids if needed
Order review: D/C Augmentin and IV fluids D/C, cephalexin oral, influenza and pneumococcal vaccine, consult dietician, pancreatic enzymes and genetic counselling
Delirium tremens (Alcohol Withdrawal)
ED. 1. Physical Examination
Pulse Ox, Oxygen, CPR, IV access, IV NS, IV thiamine, IV folic acid, blood glucose, NPO except meds, ECG, lorazepam 2-4mg IV, every 15-20 minutes, seizure and aspiration precautions
Orders: CBC, BMP, LFTs, PTT, PT/INR, Serum magnesium and serum phosphorus, blood culture, ABG, urine toxicology, blood alcohol levels, CXR, CT scan of head, lumbar puncture.
IV 50% glucose, admit to ward with continuous telemetry monitoring, continue IV fluids with thiamine, multivitamin, folic acid, replete mg and phosphorus, monitor electrolytes Q4-6 hrs, neuro checks Q2-4 hrs, lorazepam, haloperidol, acetaminophen for fever and ondansetron for nausea,
When patient is stable, stop lorazepam and start chlordiazepoxide.
Rehab, alcohol anonymous, safe sex, limit alcohol, smoking cessation, seat belt use, safety plan,
Jaundice
vital signs, Physical exam including input/output
Order: blood typing of mother and infant, direct Coomb's test, CRP, CBC with differential, total and indirect bilirubin, input/output, vitals Q 4 hrs.
Order: Hb, hematocrit Q 8hr, total bilirubin Q 8hr, continue po feeding, breast milk, supplement with formula, vital signs Q 4hr
Bilirubin increased, shift to NICU, phototherapy, erythromycin ointment for eyes, IV fluids,
When bilirubin levels start falling, phototherapy discontinued, D/C IV fluids, Followup total bilirubin Q daily.
Acute gastroenteritis
Physical Examination
IV access, CBC with differential, BMP, Urine analysis, IV NS, Stool heme, stool leukocytes, stool culture, breast feeding
Admit ward/floor, potassium, vitals Q4, recheck BMP, repeat physical examination, BMP normal discharge patient home
Add antibiotics according to the stool culture results
Polycystic Ovarian Disease
Physical Examination
Urine B-HCG test, testosterone free and total, DHEAS, prolactin, 24 hr urine cortisol, 2 hr urine 17 ketosteroid, TSH, FSH, LH, Pelvic U/S
Review Orders: Fasting lipid profile, Glucose tolerance test, Patient education/counselling, weight reduction, low fat/low calories diet, regular exercise. OCP, PAP smear,
Follow-up in 1 week with results.