Case 1 DKA

● Management
○ Check Ca2+---life threatening complications if too high
○ Check Serum Osmolality, Serum Ketones, ABG, UA, EKG,
○ Give anti-nausea (Promethazine)
○ Differentials non-invasive check (amylase, lipase)
■ Abdominal Path, Menstrual, DKA, Nonketotic Hypersomlar, Alcoholic
Ketoacidosis, Drug Intoxication
○ Admit to ICU, NPO, Bed rest, Vitals, Urine Output, KCl, HbA1c, follow BMP (2-4
hrs), ABG 2 hrs, after 4 hrs--½ NS IV.
○ Monitor K, CXR/BC/UA/UC--consider Abx. If nausea good, Oral fluids. Stabilize
and then transfer to floors.
○ Discharge--D/C Insulin, IVF, Cardiac. NPH Insulin, Regular Insulin, Diabetic
Diet, Counseling, Foot Care. F/u in 10 days.
● Theory
○ Potassium when K+ < 5.3.
○ Bicarbonate when pH < 7.1.
○ Fluids to ½ NS when stable BP, good urine output, pt improving.
○ When glucose < 250, add dextrose.

Case 2 Unconscious Patient

● Management
○ Step 1--Respiratory Exam + Stabilize Pt
■ Airway (Oxygen, Pulse Oxy, Suctioning)
■ Breathing (Intubation if PaO2 <55 or PaCO2 >50 on ABG)
■ Circulation (IVA, Cardiac Monitor, Foley, Finger Glucose, IVF)
■ Drugs--Give Thiamine, Naloxone, Dextrose
○ Step 2--Full PE
○ Step 3--Diagnostic Investigations & Initial Tx
■ CBC, BMP, UA, EKG, CXR, LFTS, Urine Tox, B-HCG, Blood Etoh
■ If opiate OD: NG tube, Gastric Lavage, Charcoal, Naloxone IV cont.
○ Step 4--Standard Monitoring Protocols
■ ICU, NPO, Bed Rest, Urine Output, BMP Next Day
○ Step 5--Pt is Stable
■ D/c o2, ng, cardiac monitor, ivf, naloxone, start reg diet
■ Psych consult, suicide precautions, counseling, antidepressant if needed
● Theory
○ OD patients need EKG, CXR (r/o pulmonary edema/aspiration)

Case 3 Jaundice
● Management
○ Step 1--Full PE
○ Step 2--Initial Labs
 ■ CBC, BMP, LFTS, Prothrombin
○ Step 3 Admit Pt
■ IVA, NS, Diet, Activity, Reticulocyte, Haptoglobin, LDH, UA, Type and
Cross, PRBC transfusion
■ Repeat Hb and Hct
○ Step 4
■ G6PD blood, Coombs Test, Direct
○ Step 5
■ F/U appointment, reassurance, counseling
● Theory
○ Elevated Reticulocyte count confirms hemolytic anemia. Elevated LDH and low
haptoglobin indicate that hemolysis is intravascular.
Case 4 Cystic Fibrosis
● Management
○ Step 1--Complete Physical
○ Step 2--Admit Pt
■ IVA, Pulse Ox (4hrs), Sputum Gram Stain, Sputum culture and sensitivity,
Blood Cultures,
■ CBC, BMP, CXR PA/Lateral, Sinus XR, Sweat Chloride, 72 fecal fat
■ O2 continuous (if <92), Nebulized Albuterol Inhalation (4x day), chest
physiotherapy, Vitals q6, D5NS, Regular Diet, Ambulation at will
■ Amoxicillin and Clavulanic Acid PO
○ Step 3 (when pt better)
■ D/C Abx & IVF
■ Give Cephalexin (PO), Influenza, Pneumococcal vaccine, consult
dietitian, pancreatic enzymes, genetic counseling.
■ F/U 2-3 months.
● Theory
○ Clinical Manifestations include respiratory sxs, failure to thrive, meconium ileus,
diarrhea, rectal prolapse, nasal polyps, acid-base disorders, hepatobiliary dz.
○ Need elevated sweat chloride x 2.
○ PPx immunization against influenza, measles, pertussis.
○ Abx when increase in sputum production, cough, or dyspnea/fever. Staph A--
Cephalexin, Dicloxacillin or Amoxicillin-Clavulanate. Pseudomonas--Cipro (PO)
or IV Tobramycin and Piperacillin (as an example).
Case 5 CHF (Shortness of Breath)
● Management
○ Step 1--Initial Orders
■ Elevate the head of bed, pulse oxy, O2, IVA, Cardiac Monitor, EKG
○ Step 2--PE
■ General, HEENT/Neck (JVD), Heart, Lungs, Abdomen, Extremities
○ Step 3--Initial Labs
■ CBC, BMP, BNP, Troponin (q6hrs x2), LFTS, CXR
■ Furosemide
 ■ This pt already on BB, ACE-I
○ Step 4--Admit to General Floor
■ Telemetry, Low-salt, low-cholesterol, diabetic diet (pt was DM)
■ Ambulate at Will
■ Fluid Restriction, Monitor Input/Output, Daily weights
■ KCl as long as lasix is given, BMP next day (renal fxn, electrolytes)
■ Start sliding scale insulin, give 10 units now, accu check achs
■ HbA1c, Lipid profile, Echo, Continue all home meds ( BB, ACE-I, not
glyburide)
○ Step 5 Discharge
■ Pt education, cardiac rehab, exercise, diet/med compliance. F/u 1 week.
Case 6 Decreased Acute Renal Failure & AMS
● Management
○ Step 1--If ABC stable--Complete PE
○ Step 2--Initial Management
■ Pulse ox, IVA, 12 lead ECG, ABG, CBC, BMP
■ Mg and Phosphate
■ Foley Catheter, NS Fluid Bolus followed by continuous drip
■ UA, UC, Urine Sodium and Creatinine
○ Step 3--Continue Pt Specific Care
■ Transfer to floors, continue meds (minus reno-toxic--ACE-I, NSAID, etc),
complete bed rest until return to normal mental status.
■ Vitals, 24hr urine protein, daily weights, input and output, Renal US
■ Heparin 5000 SQ q12hrs
■ Accu checks qid, HbA1c, sliding scale insulin
○ Step 4--Post mental status improvement
■ D/C bed rest, out of bed to chair, d/c foley, continue renal diet, PO fluids
● Theory
○ If Potassium is elevated, give D5/Insulin and recheck potassium
○ If taking nephrotoxic drugs (ex NSAIDS, ACE-I--creatinine 2+) stop them
○ Prerenal vs Renal vs Postrenal failure
○ If Fever--BC and start Abx (Cipro)
○ If Obstruction--urology consult, Renal US, and Catheterize
Case 7 Pediatric Acute Gastroentritis
● Management
○ Step 1--IF ABC Stable--Complete PE
○ Step 2--Initial Management
■ IVA, CBC, BMP, UA, IV NS bolus, IV NS continuous, Stool Culture, Stool
leukocytes, heme check
○ Step 3--Admit to Floors
■ Replete Electrolytes (K+), Vitals q4hrs, Recheck BMP next day, Repeat
PE 4-6 hrs
■ Once adequately hydrated--discharge
● Theory
 ○ Viral vs Bacterial vs Otitis Media vs UTI vs Intussusception, Appendicitis,
Hyperconcentrated Infant Formula, etc.
○ Stool heme (+)--stool culture
○ Past Abx--send for C.difficile antigen
○ Winter months--Rotavirus assay
○ Campylobacter: Erythromycin, C.Diff: MTZ, Salmonella: Fluoroquinolones,
Azithromycine, or Ceftriaxone. Giardia: MTZ.
Case 8 Polycystic Ovarian Syndrome
● Management
○ Step 1--Complete PE
○ Step 2--Initial Management
■ Pregnancy test, LH, FSH, DHEAS, TSH, Prolactin, 24 hr Urine Cortisol,
24 hr urine 17-ketosteroids, Serum Testosterone total and free, Pelvic
US, f/u when results available.
○ Step 3--Follow-up
■ Fasting lipid, glucose tolerance test, pap smear
■ Counsel pt, weight reduction, low fat/calorie diet, exercise, OCPS, f/u in 1
week.
● Theory
○ Must distinguish between causes of hirsutism, weight gain, amenorrhea. Test
thyroid, prolactin, late onset-CAH, Cushings.
○ If androgen secreting tumor--low serum LH is seen. Serum testosterone and
DHEAS are high in ovarian and adrenal tumors respectively.
Case 9 Alcohol Withdrawal
● Management
○ Step 1--Physical Exam--General, HEENT/Neck, Heart and Lungs, Abdomen,
Extremities, and Neuropsychiatric.
○ Step 2--Initial Management
■ Pulse Oximeter, Supplemental O2, Cardiorespiratory monitoring, IVa, IV
NS bolus and continuous, IV thiamine, IV folic acid, blood glucose, NPO,
ECG, Lorazepam, Seizure and Aspiration precautions.
■ CBC, BMP, LFTs, PTT, PT/INR, Serum Mg and Phosphorus test, Blood
Culture, ABGs, Urine Toxicology, Blood Alcohol, CXR
(aspiration/ams/infection), CT, LP (to exclude meningitis if fever,
meningeal signs, leukocytosis)
○ Step 3--Admit to General Ward
■ IV glucose, IV fluids, Add dextrose, Replete Mg and Phosphorus (replete
if needed), Monitor and repeat electrolytes, frequent neuro checks (2-
4hrs), lorazepam, Haloperidol if needed
○ Step 4--Post-Recovery
■ Rehabilitation, AAA, Counseling
Case 10 ABO Incompatibility Jaundice
● Management
 ○ Step 1--Review Vitals, Full PE, Check Inputs/Outputs
○ Step 2--Blood typing, Direct Coombs Test, CRP q 12 hr, CBC with differential,
Total and Indirect Bilirubin, Inputs/Outputs, Vital Signs q 4hrs
○ Step 3--Hgb and Hct q 8hrs, Total Bilirubin q 8hrs, Continue po feeding, Vital
Signs q4 hr
○ Step 4--Transfer to NICU (ICU) if necessary, phototherapy, erythromycin
(ointment for eyes while receiving phototherapy)
○ Step 5--Discontinue IVF, Phototherapy, follow bilirubin until stable
● Theory
○ ABO incompatibility is present in first day
○ Breast Milk Jaundice and other pathological causes later in week
○ Biliary Atresia, Hypothyroidism, Galactosemia, Spherocytosis, 6GPD def
Case 11 Nephrotic Syndrome
● Management
○ Step 1--Full PE
○ Step 2--CBC with diff, BMP, U/A, LFTS, Lipid Panel, PT/INR, PTT, Complement
3 and 4 levels
○ Step 3--Admit to floors, Inputs/Outputs, Vitals q4 hrs, Nephrology Consult,
Albumin 25% solution IV over 8 hrs, Lasix (start halfway through albumin), CMP
q AM, No salt added/high protein diet
○ Step 4--Add Prednisone, vitals q 12 hrs, repeat albumin + lasix
○ Step 5--Discharge---Discharge, Prednisone 4-6 weeks, f/u in 3-5 days
● Theory
○ Criteria--Generalized edema (ex: face, scrotum,labia, pretibial), Hypoproteinemia
and low albumin relative to globulin levels), Cholesterol >200
○ Increased risk of thrombosis--so must get coagulation studies (if serious risk,
start Heparin 50 units IV and 100 units every 4 hrs)
○ Usual approach--give albumin of 25% solution and infuse over 8-12 hrs in
supervision of HF. Then lasix and prednisone (4-6 weeks)
○ If stable, no pulmonary edema, and good diuretic response---don’t need to stay
past 2-3 days.
Case 12 Group B Strep Pneumonia
● Management
○ Step 1--Pulse Ox + PE (full)
○ Step 2--IV, Supplemental O2, CBC, BMP, BC/UC/CSF Cx, CSF for
protein/glucose/cell count/gram stain, CXR--PNA, CRP
○ Step 3--Admit to Floors---Continuous cardiorespiratory monitoring, vitals q4, diet
no oral if RR >60, IVF, Amp + Cefotaximine, Inputs/Outputs, CBC/BMP q daily
○ Step 4--Examine pt every 2-4 hrs until improvement, then 8-12 hrs, diet (po when
rr<60) and o2 (wean off when >94),
○ Discharge Home--change abx to amoxicillin
● Theory
○ MCC of infection at this age (6 days) are E.Coli or Group B strep. Others include
H. Infuenza, Strep Pneumo, Group B strep, Listeria, Anaerobes.
 ○ If maternal hx of group b strep--and recieved tx---still tx
○ HSV warrants treatment. Consider CMV if abx show no improvement
Case 13 Child Intoxiciation (Etoh)/AMS
● Management
○ Step 1--PE (General, HEENT, Heart, Lung, Abdomen, Msk, Neuro) + Pulse ox,
supplemental o2, monitior cardioresp, finger stick glucose, iv lock, urine tox,
naloxone
○ Step 2--D50, IVF, Blood Etoh level, Serum toxicology, bmp, cbc, accuchecks
q1hr
○ Step 3--Admit floors, IVF, D5, KCL, NPO until awake, BMP in AM, repart BAL in
12hrs
○ Step 4--discharge, pt education, screen abuse/domestic violence
Case 14 Subarachnoid Hemorrhage
● Management
○ Differentials: Migrane, SAH, Temporal Arteritis, Glaucoma, Tension HA, Sinusitis
○ Step 1--PE--Gen, HEENT/Neck, Lungs, Heart, Abdomen, CNS, Extremities
○ Step 2--IVA, IV Ketorolac, ESR, CT Head w/o Contrast
○ Step 3--If CT non-diagnostic, LP
○ Step 4--Admit to ICU--cardiac monitoring, pulse ox q2 hrs, NPO, complete bed
rest, urine outputs, neurochecks q 1hr, CBC, BMP, EKG x 1, PT/INR/PTT,
Transcranial doppler (not in software?), IVF, Neurosurgery consult,
acetaminophen with codeine PO, stool softner, Nimodipine PO 21 days, PPI,
Pneumatic Compression
○ Keep BP btwn 120-140, if too high IV labetolol. If low, IV pressors + NS bolus
○ Lastly--4 vessel angiogram
Case 15 Hyperthyroidism (outpt, 98)
● Management
○ Step 1---Complete PE
○ Step 2--CBC, BMP, EKG, TSH, Free T3 T4, hCG
○ Step 3--24 hour radioiodine uptake test, thyroid US, autoantibodies
○ Step 4--Propranolol, Methimazole PO daily, f/u in 4 weeks (withhold methimazole
4 days prior to appointment)
○ Step 5--CBC with diff, Stop Methimazole, Radioiodine ablation, f/u 1 month
● Theory
○ If high risk patients (risk of developing VTach), then eval with ambulatory
monitoring or electrophysiology study
■ H/o syncopy or dizziness, fhx of sudden cardiac death, organic heart dz
○ If TSH, T3, and T4 are elevated...need MRI of brain for pituitary tumor.
○ Subacute and Postpartum thyroiditis only require sxs tx
○ Pregnancy test before radioiodine uptake, BB/CCB if tachycardic
Case 16 Lead Poisoning/IDA (26)
● Management
○ Step 1--Complete PE
 ○ Step 2--CBC, BMP, Blood Lead, Calcium, U/A, Milk of Magnesia, Docusate, F/u
3-5 days
○ Step 3--Venous Blood (not available?)---
○ Step 4--Lead Paint Assay at Home, Serum Iron, Ferritin, TIBC, Succimer, LFTS,
Erythrocyte Protoporphyrin (baseline needed for succimer, as well as CBC)
○ Step 5--If home is source of lead---”lead abatement agency”
○ Step 6- Repeat Blood Lead, CBC, Erythrocyte Protoporphyrin
○ Counseling on limiting cow's milk intake if applicable, Calcium rich diet, Iron-
enriched diet
● Theory
○ Sxs--Abdominal Pain/Constipation, motor neuropathy, fatigue. May be axs--
microcytic anemia + basophilic stippling on CBC
○ Blood Lead >9 warrants concern. If 45+ 1 chelation agent. If 69+, 2 agents
(succimer, calcium ededate, dimercaprol, D-penicillamine)
Case 17 Lung Cancer with PNA(58)
● Management
○ Step 1 (Outpt)-Pulse Oximeter, PE--HEENT, Lungs, Heart, Abdomen,
Extremities
○ Step 2--Shift to Hospital Ward
■ Pulse Oximeter, O2, IVA, IVF, Vitals q4hrs, urine output q4hrs, Bedrest
with Bathroom Priv.
■ CBC, BMP, CXR, BC, Sputum for gram stain/culture/cytology,
■ Levofloxacin, Albuterol, Ipratropium
○ Step 3--CT Chest (Staging), Bronchoscopy (Lavage for cytology, gram stain,
culture, AFB smear, fungal culture), Consult with pulmonary med/cv surgeon,
CBC/BMP daily, O2
○ Step 4--Further Diagnostics
■ PFTs, LFTS, Ca, quit tobacco, high protein diet
■ CT of Abdomen/Pelvis, MRI Brain w/o contrast, Bone Scan---all for
metastasis.
■ Consult Radiation Oncologist, Oncology
● Theory
○ May present with shoulder pain or recurrent PNA with smoking history.
○ If SIADH--hyponatremia sxs (anorexia, nausea, cramps, HA)---demeclocycline
and fluid restriction
Case 18 Bacterial Meningitis (115)
● Management
○ Step 1--Physical Exam--HEENT, CNS, Heart, Lungs, Abdomen, Extremities, Skin
○ Step 2--Initial Management
■ Pulse Oximeter, IVA, IVF, NPO, Complete Bed Rest, Vitals q2hrs, Urine
output q2hrs, Head elevation, Pneumatic Compression Stockings
■ BC, UA, UC +sensitivity, CBC, BMP, PT/PTT/INR
■ Phenergan IV for vomiting, Acetaminophen for fever + HA
○ Step 3--Initial Antibiotics
 ■ Infants <3m--Cefoxitin (Gram -) + Ampicillin (Listeria) +add
Dexamethasone if H. Influenza
■ 3m to 50 years--Ceftriaxone + Vancomycin
■ 50+, IC--Ceftriaxone + Vanco + Ampicillin
■ Post Head trauma/neuro procedures/neutropenia--Vanco + Ceftazidime
(pseudomonas)
○ Step 4--LP (no CT if awake w/o FND) + CSF for cell count, protein, glucose,
gram stain, fungal stain, culture and sensitivity.
○ Step 5--Change Abx based on sensitivity, focused PE q few hrs, daily CBC, BMP
■ Meningococcus--respiratory isolation + terminal complement deficiencies
Case 19 Febrile Neutropenia 2/2 to Chemotherapy (101)
● Management
○ Step 1--Complete PE
○ Step 2--Look for infection---IVA, CBC, UA, UC + sensitivities and gram stain, BC,
Sputum GS +GC, CMP, CXR, LFTS, Empiric Abx (Ceftazidime--ex)
○ Step 3--Admit to floor, regular diet, ambulate as tolerated, vitals q4hrs,
acetaminophen as needed, cbc daily, pt/ptt, monitor/interval hx q few hrs. Id
consult.
○ Discharge--D/C IV Abx, start PO. D/c cbc. Educate pt--avoid sick ppl, come if
fever.
● Theory
○ Absolute neutrophil count < 500
○ Abx--Usually consider gram negative/pseudomonas coverage----Cefepime,
Ceftazidime, Imipenem, Meropenem. Or aminoglycoside + antipseudomonal
PCN.
○ Add Vanco if no response (3days) or hypotension, MRSA hx, or catheter infxn
○ Antifungal (amphotericin B) if neutropenia and fever persists >5-7 days
Case 20 Right Sided Infective Endocarditis (71)
● Management
○ Step 1--Complete PE (minus invasive)
○ Step 2--Initial Management
■ Pulse Ox, IVA, CBC, BMP, PT/PTT, BC every 10 min x 3,
■ UA (hematuria), CXR (Septic Emboli), ECG, Urine Toxicology
○ Step 3--Empiric Abx +Acetaminophen +IVF
■ IVDU--Vanco + Gentamicin (MRSA + Gram neg)
■ BC (-) Endocarditis--Ceftriaxone + Gentamicin
■ BC (-) Prosthetic Valve--Ceftriaxone + Gentamicin + Vancomycin
○ Step 4--Admit to Floors
■ Vitals q4hrs, Pulse Ox q4hrs, Urine Output, Bed rest with bathroom,
Pneumatic Compression Stockings, NPO
○ Step 5--Advance Clock 8 hrs--TEE + CBC next morning
■ If not tested, consider: HbsAg, Hep C Ab, HIV-1/HIV-2 serology
○ Step 6--Long term Abx
■ Switch to applicable Abx, Central line placement (for iv abx), BC 4-6wk
 ○ Step 7--Counsel--smoking, drugs, Etoh, Safe Sex , SBE ppx, etc
○ Step 8--F/u 1 week
● Theory
○ RF--IVDU, Prosthetic Heart Valve, IV Catheter

Case 21 Atrial Fibrillation (100)

● Management
○ Step 1--PE: Gen, HEENT, Lungs, Heart, Abdomen, Extremities, Neuro
○ Step 2--IVA, Pulse oximeter, EKG
○ Step 3--Cardizem IV, CBC, BMP, CXR (PA and lateral), Cardiac Enzymes q8hrs,
U/A, LFTS, TSH/Free t4, PT/INR/PTT
○ Step 4--Admit to floors
■ Telemetry, vitals q4hrs, pulse ox q4hrs, 2-D Echo,
■ Diet--consistent with status, (if diabetics--do diabetic w/u)
■ Start Cardizem IV, Start Heparin IV, PTT q6hrs, CBC daily
○ Step 5--Monitor
■ Monitor telemetry strip, repeat ekg, keep examining pt every 6 hrs and
interim hx and telemetry strip.
■ Once HR <80, d/x cardizem drip, start po. Start Coumadin on next day,
daily pt/inr
○ Step 6--Next Day
■ Check CBC, PT/INR, Strip
■ Once PT/INR >2, d/c iv heparin
■ Discharge pt, education, f/u in 3 days
● Theory
○ Anticoagulation needed if chronic AF, recurrent AF, prior and after cardioversion.
■ AF > 48 hrs requires 3-4 weeks of warfarin prior to and after cardioversion
■ Recurrent/Chronic requires long-term anticoagulation
■ High Risk pts (valve,lv dysfunction, or recent thromboembolism) should
receive anticoagulation even if < 48 hrs ...but no long term.
○ Admit pt if high risk or hemodynamically unstable.
■ Low risk patients (w/o valvular dz or severe dysfunction of LV) with AF
<48hrs can be cardioverted and discharged from ER
○ Common causes include HF, ACS, PE, HTN, Hyperthyroidism, Infections (U/A)---
must investigate
■ If 2/2 to an underlying cause--postpone cardioversion (but not
anticoagulation) until done.
Case 22 Pericardial Tamponade(64)
● Management
○ Step 1--Pulse Oxy, O2, IVA, BP Monitor, PE--General, Lungs, Heart, Extremities,
Abdomen
○ Step 2--IV NS, Elevate legs, continuous cardiac monitoring, Pericardiocentesis
○ Step 3--EKG, XR Portable, TEE, Pericardial fluid for cell count, ABG,
Cardiovascular thoracic surgeon consult, FAST
 ○ Step 4--Transfer to ICU
■ Continue cardiac monitoring, swan-ganz cath, NPO, Complete Bed Rest,
Foley, Urine Output q2hrs, Pneumatic Compression legs,
■ CBC, BMP, PT/PTT, continue fluids, Omeprazole, Type and Screen,
Acetaminophen + codeine
■ Transfuse if Hgb < 8, or Hgb<10 + active bleeding
○ Step 5--Next Day--d/c foley, repeat Tee, repeat CXR, Counsel seat belts
Case 23 Acute Pancreatitis (9)
● Management
○ Step 1--Stabilize--IVA, IVF, BP Monitoring, Pulse Ox, EKG
○ Step 2-- PE--General, HEENT, Heart, Lungs, Abdomen, Rectum, Extremities
○ Step 3--NPO, (Fentanyl/Morphine) IV Continuous, Phenergan IV (1x Nausea),
Lipase, Amylase, LFTS, Abdominal XR (r/o air under diaphragm/perforated ulcer)
portable, CBC, BMP, Ca
○ Step 4--Transfer Ward/ICu, Bed Rest, Pneumatic Compression, Omeprazole (ill
pts ICU), US Liver/GB/Biliary Tree, Urine Output
○ Step 5--PT/PTT, GI consult for ERCP, ERCP---assuming gallstones as cause
○ Step 6--Examine in 6 hrs, repeat CBC, BMP, Ca next day
● Theory
○ Differentials: Perforated Duodenal Ulcer, Acute Gastritis, Acute Cholecystitis
Case 24
Interactive Case 11 Hypertensive Urgency/Emergency (89)
● Management
○ Step 1--IVA, Pulse Oximetry, O2, Cardiac Monitor, BP Monitor
○ Step 2--PE: General, HEENT (fundoscopic), Cardiac, Lungs, Abdomen, Neuro,
Extremities
○ Step 3--EKG, Head CT, CBC, BMP, UA, CX-PA, Troponin, BNP
○ Step 4--Nitroprusside IV, Arterial Line
○ Step 5--Transfer pt to ICU, NPO, Complete Bedrest, monitor urine output
○ Step 6--Final Orders--Lipid profile, counseling
● Theory
○ End Organ Damage includes retinal hemorrhages, papilledema, encephalopathy
(n/v/ha/confusion), stroke, and malignant nephrosclerosis.
○ Head CT, CXR, BMP, UA, CBC allow diagnosis of stroke, pulmonary edema,
renal impairment, and hemolysis.
Interactive Case 17 Unstable Angina
● Management
○ Step 1--IVA, Pulse Oximetry, O2, Cardiac Monitor, BP Monitor, ASA, EKG,
Nitroglycerine (sublingual, one time)
○ Step 2--PE (General, HEENT, CV, Lungs, Abdominal, Genital, Rectal,
Extremities)
○ Step 3--FOBT (must do prior to Heparin), Metoprolol (IV x1 to bring HR to 60-70)
○ Step 4--Heparin IV, PTT q6hrs, CXR-PA, CBC, Cardiac Enzymes q8hrs, BMP
 ○ Step 5--Move to ICU, NPO, bedrest, ECG, urine output, Metoprolol PO,
Simvastatin PO, Echo, Cardiology consult, Eptifibatide (GP IIB/III prior to cath),
Lipid Panel, LFTS
○ Step 6--Cardiac Cath, Coronary Angioplasty
○ Step 7--Counseling, Diet (low sodium/cholesterol), exercise, discharge meds
(ASA, BB, Statin, Nitro)
● Theory
○ Differentials--Pneumothorax, PE, Aortic Dissection
Interactive Case 18 Croup (63)
● Management
○ Step 1--Pulse Ox, Oxygen
○ Step 2--Complete PE
○ Step 3--CBC, Neck XR, Humidified Air, Dexamethasone Oral, Epinephrine
Inhalation
○ Step 4--Advance clock and interval follow up/focused physical
○ Step 5--Evaluate for a few hrs, if stable, discharge (parent counsel)
■ D/C all treatment
● Theory
○ Differentials--Bacterial Croup, Epiglotittis, Tracheitis, Peritonsillar Abscess,
Foreign Body Ingestion. 1st 4 have high fever + abrupt + severe respiratory sxs.
○ Mild Croup--Humidified mist and oxygen + PO Dexamethasone
○ Moderate Croup (ex at rest): Add Inhaled Epi. If still not improve, admit--consider
bacterial (2nd gen cephalosporin).
Interactive Case 22 Septic Arthritis (56)
● Management
○ Step 1--Complete PE
○ Step 2--Admit to Wards
■ CBC, BMP, ESR, PT/INR, PTT, Blood Cultures, Knee X-ray, Synovial
gram stain, synovial fluid cell count, synovial glucose, synovial fluid
crystals, synovial fluid culture and sensitivity, synovial fluid viscosity
○ Step 3--Initial Management
■ NPO, IVA, IVF, Morphine (IV 1x), Acetaminophen PO, Ceftriaxone +
Vancomycin IV after arthrocentesis, Orthopedic Surgery Consult
■ Vanco for MRSA, Ceftriaxone for Gram negative rods or gonococcal
○ Step 4--Management based on results
■ Arthroscopy + cancel whichever Abx not needed
■ After arthroscopy--normal diet
○ Step 5--Advance clock, re-evaluate, counsel
● Theory
○ Arthroscopy done to drain joint fluid
Interactive Case 24 Pericarditis
● Management
○ Step 1--Pulse Oximetry, O2, Cardiac Monitor, BP Monitor, ECG
 ○ Step 2--PE--General, Skin, HEENT, CV, Lungs, Abdominal, Extremities
○ Step 3--CBC, BMP, CXR, Cardiac Enzymes, ESR, BC, Ibuprofen, Colchicine
○ Step 4--Admit to Floors, Ambulate at will, reassurance, regular diet, Echo, Cancel
O2
○ Step 5--Cancel Cardiac Monitor, BP Monitor, IV access. Evaluate patient until
sxs improve.
○ Step 6--Counseling
○ Step 7--Discharge and f/u in 2 weeks
● Theory
○ CBC--infxn, inflammation, BMP--uremia, echo/cxr for tamponade eval
○ Tb,ana, hiv may be considered.
○ Avoid NSAIDs in post MI pericarditis. Steroids if tx resistant
○ Pericardiocentesis only if large effusion or tamponade.
Interactive Case 32 Hypertension(93)
● Management
○ Step 1--Complete PE--looking for signs of End organ damage
■ Fundoscopy--End Organ Damage
■ Pulse Palpation--Coarctation of Aorta
■ Cardiac--LVH
■ Abdominal--Renal Artery Bruit
○ Step 2--Workup and Counseling
■ CBC, BMP, UA, Lipid Profile, ECG, fasting glucose, renal US, urine tox,
uric acid--for younger patient
■ Low Salt Diet, Exercise, No smoking, No Etoh, Low Fat, Calorie restricted
○ Step 3--See pt again in 90-120 days (do this twice) and check bp/vitals--
assuming essential hypertension (not 2/2 to cause)
○ Step 4--In third overall appointment---order oral BP med (preferably CCB like
amlodipine or ace-i/arb). Comorbid conditions--manage bp accordingly.
● Theory
○ May consider urine catechoalmines, dexamethasone suppression test, renal
artery angiogram (RAS), karyotype (Turner), TSH, ANA (Lupus) depending on
individual patient.
http://www.usmleforum.com/files/forum/2011/5/576309.php
Crush CS Cases Done
5, 25, 26, 46, 58,63, 64, 71,82, 89, 93, 98, 100, 101, 115, 118