Vital signs: Blood pressure:137/79 supine, 124/68 erect; Heart rate: 85/min, regular; Respirations: 16/min; Temperature 38.8C.
C.C: Cough. HPI:
The patient is a 65-year-old white male with a past medical history significant for COPD with a 60-pack-year smoking history. He continues to smoke cigarettes
occasionally, although he has recently cut back. He presents with a five-day history of increasing cough, increased sputum production and fever up to 38.7 for the last two days. He has dyspnea on exertion and currently has some mild dyspnea. He’s had decreased appetite, poor PO intake and a ten pound weight loss over the past two months. ROS: He denies any chills, hemoptysis, chest pain, pleuritic chest pain, abdominal symptoms/pain, diarrhea, constipation, blood per rectum, or melena. He denies any neurologic symptoms. The rest of his
review of systems is negative. He had a similar illness approximately seven to eight weeks ago which was treated with cefuroxime and azithromycin, and the
patient reports that after that course of treatment he got better and has been well for the past three weeks until the last five days when he had return of the
cough, increased sputum production and fever. FH: Nothing significant. Medications: Takes albuterol puffs as needed. Allergies: None
How to approach this case:
The patient is an elderly man with a significant history of COPD now presenting with a second pneumonia in the course of about two months. He needs an
evaluation right now of his O2 saturation, physical exam, and then an exploration into the etiologies behind his recurrent pneumonia. The suspicion for malignancy is very high given his 60-pack-year smoking history, the weight
loss noted in the review of systems, and the recurrence of a pneumonia, particularly if the pneumonia is in the same place as the prior one.
Orders: Pulse oximetry
Results:
O2 saturation 90% on room air Order:
Physical exam: HEENT/Neck, lungs, heart, abdomen, and extremities, Results:
General: Elderly white male in no acute distress with temporal wasting. HEENT shows a clear oropharynx with upper and lower dentures. There is no neck lymphadenopathy. Temporal wasting is present. Conjunctivae are slightly pale. Cardiovascular is normal. Lungs: Decreased breath sounds throughout with rales
present on the right upper lung fields posteriorly and decreased breath sounds in the right upper lung anteriorly. Increased anterior posterior distance on
the chest with barrel chest habitus, and mild supraclavicular retractions. Abdomen: Slightly obese but otherwise normal. Extremities: There is bilateral tenderness of wrists, with nails more curved longitudinally and base of nail bed
fluctuant in all fingers. Right index finger and middle finger show nicotine staining.
Discussion:
The patient has hypertrophic osteoarthropathy noticed on examination. It is characterized as chronic proliferative periostitis of long bones, clubbing of fingers and synovitis. It is more related with squamous and adenocarcinoma of the lungs. Symptoms of this condition may occur before the actual manifestation of lung carcinoma. As a No.1 killer Cancer in USA, it remains very important to know the different manifestations of lung carcinoma. This patient’s finding of hypertrophic osteoarthropathy is significant for lung carcinoma in the context
of his recurrent pneumonia and dyspnea. Orders:
Shift to hospital ward.
Begin supplemental oxygen therapy at 2 lpm by nasal cannula (Type oxygen inhalation)
IV access
IV fluids at 100 cc an hour with normal saline Urine outputs, Q 4 hours
Vitals: Every 4 hours Pulse oximetry every 4hours
Activity: Bed rest with bathroom privileges Chest X-ray, PA and lateral, stat
Blood cultures, stat
Coughed sputum sample for gram stain, culture and cytology. CBC with differential, stat
Basic metabolic panel, stat
Begin antibiotic therapy with Levofloxacin (Levaquin) orally or IV after cultures obtained
Albuterol and ipratropium nebulized treatments Q6 H and albuterol Q2H PRN for shortness of breath.
Results:
Chest X ray shows an infiltrate in the right upper lobe with some elevation of the transverse/minor fissure anteriorly. There are no effusions. There is
evidence of hyperinflation and chronic lung changes.
Whenever Ca lung is suspected on the basis of clinical features and initial diagnostic tests, we need to perform advanced imaging procedures and other tests
to establish the tissue diagnosis of lung cancer. CT scan of chest is done for mediastinal and pleural extension of the suspected lung tumor. For tissue
diagnosis of the lung Ca following diagnostic modalities are available: Sputum cytology
Biopsy of suspicious lymph nodes
Flexible fiberoptic bronchoscopy: Biopsy specimens are taken when any endobronchial lesion is noted
Pleural biopsy if pleural effusion is present
Mediastinoscopy and anterior mediastinotomy when there is suspicion of mediastinum involvement by the tumor
Transthoracic FNA biopsy under CT or fluoroscopic guidance when a peripheral pulmonary nodule is present
Order review: Spiral CT scan of the chest
Arrange for bronchoscopy
Consult Pulmonary Medicine/cardiovascular surgery for bronchoscopy CBC/diff with basic metabolic panel daily
Continue supplemental oxygen therapy Results:
The patient undergoes bronchoscopic examination the following day. He tolerates the procedure well. Broncho Alveolar Lavage (BAL) samples are sent for
cytology, gram stain, culture, AFB smear, and fungal culture. The patient continues to show slight improvement in his oxygen saturations and overall function with the levofloxacin therapy. His IV fluids can be discontinued. His
supplemental oxygen can be weaned to room air.
Results of the bronchoscopy showed an endobronchial lesion in the takeoff of the right superior bronchus. The area was biopsied and brushed. Cytology reveals malignant cells consistent with a bronchogenic carcinoma and cytology reveals
small cell carcinoma of the lung. Order:
Pulmonary Function Tests (PFT) Liver Function Tests (LFT)
Serum calcium , stat CT of the abdomen and pelvis MRI brain with and without contrast
Bone scan Consult oncology Consult radiation oncologist
Quit tobacco use
Supplement diet with high protein nutritional shakes
Consider changing albuterol/ipratropium nebulizer to MDI (Metered dose Inhalers) Primary diagnosis:
Bronchogenic carcinoma presenting as obstructive pneumonia Discussion:
Lung cancer incidence is about 3-5 per 1000 persons per year and the majority of patients are symptomatic at presentation. Local symptoms include cough (70%),
hemoptysis (40%), dyspnea (40%), chest pain, hoarseness, superior vena cava obstruction, and wheezing. Systemic symptoms include weight loss, anorexia, weakness, and fever. Signs on exam include bone pain, hepatic dysfunction, lymphadenopathy, and neurological or cranial nerve involvement. Almost all patients diagnosed have constitutional symptoms, such as the case above. Lung
cancers typically metastasize to bone, liver, lymphnodes, brain, and soft tissue. Unfortunately, screening with chest radiography and sputum cytology in
patients at risk has not been found to decrease cancer mortality although it may detect disease at an earlier stage.
Work up of suspected cases includes bronchoscopy for cytology and visualization, as well as High Resolution CT (HRCT) of the chest. If small cell
lung cancer is found, then an MRI or CT of the brain, CT of the abdomen and pelvis, and bone scan should be performed in all patients because of the high
incidence of micro/macro metastasis by the time of diagnosis. Bone marrow aspiration/biopsy is warranted in patients of SCLC (small cell carcinoma of the lungs) when there is cytopenia or increased LDH. This workup is also indicated in patients of NSCLC in whom involvement of the specific organs is suspected.
PFT’s with diffusion capacity, spirometry, and oxygen saturations should be obtained early on. After staging has been completed, about 30-40% of patients
will have limited stage disease and 60-70% will have extensive disease. 55) Location: Emergency room
Vitals: B.P: 110/70 mmHg; P.R:100/minute; Temperature: 1020F; R.R: 15/minute. C.C: Fever and chills.
HPI:
A 54-year-old retired businessman is brought into the emergency room. Family members report that he has had a mild fever, chills, and body aches, for two
days. However, this morning the patient exhibited a high-grade fever with chills, rigors, altered mental status, and a severe headache. He is nauseated and had non-bloody vomiting. The patient denies any neck pain, sensory changes
in his extremities, weakness, seizures, or visual changes. His bowel and bladder functions are intact. PMH: Significant for hypertension the last ten years and has been taking atenolol 50 mg. once daily. SH: He denies smoking or drinking alcohol. He has no known allergies. FH: Nothing significant. ROS: No
H/O head trauma. Rest is unremarkable. How would you approach this patient?
This is a 54-year old male with a two to three day history of high-grade fever with chills, severe headache, vomiting, and altered mental status. The most
likely diagnosis is either meningitis or encephalitis. It is difficult to differentiate encephalitis from meningitis, on clinical grounds alone. All
patients should be treated as having meningitis, until proven otherwise. Order physical examination:
HEENT/Neck CNS
Heart Lungs Abdomen Extremities Skin Results:
On general examination the patient appears alert, awake, and oriented to time, place, and person. The patient appears mildly confused, and sleepy. He appears very ill. The only positive findings on exam are neck stiffness and Kernig sign.
No focus of infection or other abnormalities are found. Fundoscopy did not reveal any papilledema.
Orders:
Pulse oximetry, stat and every two hours IV access
IV NS, 100 cc/hr NPO except medications
Hold his atenolol Complete bed rest
DVT prophylaxis (Type 'Pneumatic compression stockings') Vitals Q 2 hours
Urine output every two hours Head elevation
Blood cultures, stat Urinalysis, stat
Urine culture and sensitivity, stat CBC with diff, stat and Q day
BMP, stat and Q day PT/INR, stat
PTT, stat
Phenergan, IV PRN for vomiting
Acetaminophen, oral, PRN for headache and fever Once the blood cultures are obtained:
IV ceftriaxone, continuous IV vancomycin, continuous
Lumbar puncture, stat
Send the CSF for cell count, protein, glucose, Gram stain, Fungal stain, culture, and sensitivity
Results:
Gram stain of the CSF shows Gram positive cocci CBC showed elevated white count with left shift
BMP is normal
PT/INR/PTT is within normal limits Review orders:
Change the antibiotic according to the organism and sensitivities. Do not forget to stop the initial or unnecessary antibiotics.
Order interim history and focused physical exam every four hours until you see improvement, then Q12 hours.
Once the mentation is improved start clear liquids, then advance the diet. Order 'out of bed to chair'.
D/C daily CBC with diff, and BMP when no longer required. Discussion:
to be hospitalized immediately because of his altered mental status. The patient should be kept NPO. Start IV with normal saline because the patient is on NPO
and his diastolic blood pressure is 70, in spite of having a history of hypertension. Blood should be drawn immediately and sent for CBC with a differential, BMP, blood cultures, and coagulation studies (PT, INR and PTT to
rule out the possibility of DIC and to obtain his baseline coagulation studies). Immediately after ordering these investigations, intravenous antibiotics should
be started which are mostly empirical. The use of prior imaging studies, like a CT scan of the brain, is not necessary to proceed with a lumbar puncture. In a patient with a normal level of consciousness, without any focal neurological signs, a lumbar puncture can be safely performed even without prior imaging studies. We recommend starting intravenous antibiotics, even before obtaining a
lumbar puncture. Antibiotic therapy for several hours, prior to lumbar puncture, will not significantly alter the CSF, WBC count, glucose concentration, or the results of culture. However, blood cultures should be obtained prior to starting
antibiotics. CSF should be sent for gram stain, culture and sensitivity, protein, glucose, and cell count with a differential. If the patient has a history of seizures, with focal neurological signs, herpes simplex should be
considered and empirical IV acyclovir should be started along with IV antibiotics. In all HIV patients, CSF should be sent for cryptococcal antigen
assay to rule out cryptococcal meningitis.
In acute bacterial meningitis, the CSF, WBC count will be elevated and red blood cells will be absent unless there is a traumatic tap. Glucose is usually low (less than 40 mg/dl) and the protein is elevated (more than 40 mg/dl). Gram
stain is usually positive in 70-90% of untreated patients and culture is positive in around 80% of cases. The use of empirical antibiotics depends on the
patient's age and risk factors.
In infants of less than three months, cefoxitin plus ampicillin should be given. Cefoxitin covers most of the gram negatives and ampicillin is to cover
Listeria meningitis. Dexamethasone has been indicated for H. influenza meningitis.
Immunocompetent children of more than three months to adults age of less than 50 years should receive a third generation cephalosporin, preferably
ceftriaxone plus vancomycin.
Adults of more than 50 years of age and individuals with alcoholism or other debilitating illnesses should receive ceftriaxone plus vancomycin plus
ampicillin (to cover Listeria).
Meningitis, which develops after head trauma, or neurosurgical procedures, or in patients with neutropenia, should receive vancomycin plus ceftazidime.
Ceftazidime covers gram-negative organisms, preferably Pseudomonas. Once the organism has been identified on gram stain, antibiotics should be directed against a specific organism. If you find gram-negative bacilli on the gram stain, ceftriaxone again is the drug of choice. If you find a Pseudomonas
on the gram stain and the culture, the drug of choice is IV ceftazidime. If you find gram-positive cocci in clusters (staphylococcus), IV nafcillin is the drug of choice. First generation cephalosporins should not be used for staphylococcus
infections because they do not have high permeability into the CSF. IV vancomycin is the drug of choice for penicillin allergic patients and methicillin resistant Staph aureus. If the Gram stain shows Haemophilus
influenza, IV ceftriaxone is the drug of choice. If the patient is having meningococcal meningitis, the patient should be placed in respiratory isolation
and the patient can be tested for terminal component complement deficiencies (C6-C9). If you identify Listeria monocytogenes and the patient is an immunocompromised or undergoing dialysis, IV ampicillin plus IV gentamicin
should be given for at least three to four weeks. Usually the period of antibiotic doses is in between 10-14 days of intravenous antibiotics.
Primary diagnosis: Bacterial meningitis
56) Location: Office
Vitals: B.P: 140/80 mm Hg; P.R: 88/min; R.R: 18min; Temperature: 38.1C. C.C: Pain and swelling of the right leg.
HPI:
A 38-yr old white female, who is otherwise healthy, presents to office with two to three day history of pain and redness of the right leg. The pain continues despite applying heat and elevating the legs. There is a mild fever today. She
denies any trauma, tick or insect bites, joint pains, or prior episodes of similar problems. She has no other medical problems except menstrual abnormalities. Her gynecologist placed her on oral contraceptive pills. FH: Her mother has a H/O rheumatoid arthritis. SH: She smokes less than half a pack of cigarettes per day. Drinks alcohol on the weekends. SxH: Sexually active with
her husband. ROS: unremarkable. How do you approach this case?
Consider differential diagnosis: Deep vein thrombosis Cellulitis/Lymphangitis Superficial thrombophlebitis
Rupture of the Bakers cyst Hematoma
Order physical examination: General HEENT/Neck Lungs Heart Abdomen Extremities Skin Results:
Exam is remarkable for a palpable cord, edema, warmth, and superficial venous dilation of the right lower extremity. There is no source of infection noted on
careful examination of foot. Rest of the exam is unremarkable. Order:
Transfer to ER Pulse oximetry, stat
Compressive ultrasonogram of the right leg (Type 'Venous doppler, lower leg'), stat
D-dimer, stat CBC with diff, stat
Pulse oximetry shows 95% on room air
USG shows deep vein thrombosis of the popliteal vein
CBC shows Hb of 14, WBC of 12,000 with no bandemia, and platelet count of 220,000. Order: Rectal exam FOBT, stat PT/INR, stat PTT, stat
D/C Oral contraceptive pills Results:
Rectal exam is normal FOBT is negative PT is 13.6; INR is 0.9
PTT is 24 Order:
LMWH (Enoxaparin), stat and Q 12 hours, sub cutaneously Acetaminophen and oxycodone for pain as needed Anticoagulation teaching (Type 'patient education')
No smoking
Discharge to home with follow up in office next day Review:
Brief physical exam and interim history Coumadin/warfarin (5 to 7.5 mg) oral, continuous
PT/INR, every day until the INR is therapeutic
Appointment with anticoagulation clinic to follow PT/INR (Option is not available in software, so you have to follow every day with PT/INR)
Platelet count, in day 3 and 5 of heparin treatment Discussion:
DVT is classified into proximal vein and calf vein thrombosis. This classification is important because proximal vein thrombosis is often
associated with embolic phenomena (Board question).
Even though contrast venography is the gold standard test for diagnosis of DVT, it is not recommended for screening purposes because it is invasive,
associated with patient discomfort, and technically difficult. The two commonly used noninvasive tests for the diagnosis of DVT are compression ultrasonography and impedance plethysmography. Studies have shown
that compression ultrasonography was superior to impedance plethysmography in guiding therapeutic strategy in patients with DVT. However, impedance
plethysmography is the preferred test for the evaluation of suspected recurrent DVT because it normalizes more quickly after a previous episode than
compression ultrasonography.
Measurement of D-dimers is useful in excluding thromboembolic phenomena because of its high negative predictive value. However, the presence of elevated D-dimer alone cannot establish a diagnosis of DVT. D-dimers should be
correlated with clinical probability, and noninvasive tests in guiding the diagnosis.
Simple DVT can be managed as an outpatient. Low molecular weight heparin (LMWH) is the treatment of choice for acute DVT. Enoxaparin is the most commonly used LMWH. Warfarin can be started within 24 hours. PT/INR should be
measured daily until the therapeutic range (2.0 to 3.0) is reached. Heparin is stopped in day five or six if the INR is therapeutic for at least two
consecutive days. A platelet count should be obtained on day three and five to monitor HIT (heparin induced thrombocytopenia). Heparin should be stopped if
there is a >50% reduction in platelet count or a total count of less than <100,000/µL.
How long should you treat DVT?
Patients with reversible risk factors (surgery, oral contraceptive pills) – 3 months
Idiopathic first time DVT – 6months
Recurrent idiopathic DVT, and patients with continuing risk factors (malignancy, inherited thrombophilia) – 12 months or more
57) Location: Office
Vital signs: P.R: 72/min; B.P: 136/80 mm Hg; Temperature: 98.6 F; R.R 20/min; Height: 130 cm; Weight 60 kg.
C.C: A 53-year-old woman comes to you with the complaint of abdominal distention HPI:
A 53-year-old African American comes to you with abdominal distention. She noticed it one week ago. Her symptoms started with the complaint of anorexia, early satiety, and abdominal discomfort the past several weeks. She is very worried something is terribly wrong inside her stomach. Her other complaints
include exertional shortness of breath and orthopnea. She never had postmenopausal bleeding, jaundice, fever, pruritus, or abdominal pain. She has never received a blood transfusion nor traveled outside USA. Her bowel movements
and bladder function are normal. She has no history of contact with a jaundice patient. She had her menarche at age 13 and menopause at age 51. Her family history is significant for breast cancer in her mother at age 65. She has been smoking less than half a pack of cigarettes per day since 30 years. During that