CDM Cases
36 yo F in ED with difficulty breathing. SOB for 24 hrs w/ mild CP with deep
inspiration and coughing w/o production. No fever. No LE edema, hx of CV
problems, or wt loss. No travel. Meds are norgestrel/ethinyl-estradiol. VSS. BMI
32kg/m2. PE: diaphoretic, CV norm, pul, with fine bibasilar rales.
Q1: What actions should be taken for this patient? (8)
Q2:ABG shows pH 7.45, pO2 90mmHg, pCO2 30mmHg. CXR shows elevated
diphragm. EGK sinus tachy. D-dimer 1.4ug/ml FEU, bhCG neg. HR 108, BP 118/70.
What action next? (4)
Q3: CTPA shows filling defects in R interlobar bulmonary arteries consistent with PE.
Pt is alert and conversant. HR 110, BP 114/68, RR 24, O2% 96. What action, if any,
should be next? - correct answer-Q1: D-dimer (with low pretest probability), but if
patient were to have a high pretest probability, skip D-dimer go to CTPA.
Q2: CTPA (ONLY do a VQ scan if CTPA is contraindicated in pregnancy or renal
insufficiency). No treatment initiated in hemodynamically stable patient since there is
bleeding risk. If unstable then its ok to treat.
Q3: Tx with enoxaparin. If patient is HDS choose anticoagulation therapy (LMWH >
UFH b/c they do not require PTT monitoring q 6hrs). If contraindicated, use IVC. If pt
is HD unstable (aka systolic BP <90 for >15 min) choose thrombolysis. If
contraindicated, emergent embolectomy.
Note: those with PE should be treated at least 3 months of outpatient
anticoagulation. Warfarin is good after heparin bridge. Other Xa inhibitors can be
used. After 3 months, ASA is used. Heme workup later would evaluate for deficiency
in antithrombin III, protein S and C, factor V leiden mutation, antiphospholipid
antibodies
67 yo F in ED. 1 hr ago, pt started having slurred speech and weakness in L arm and
leg. PMHx of 35 pack yr smoking. No current meds. T98.2, BP 180/104, HR 108, RR
19, O2% 98%. PE: anxious, unable to answer questions well, L side facial droop, 4/5
strength on left side, decreased sensation. No abnormal BG.
Q1: Single most important step? (2)
Q2: CT is unremarkable. What is the most appropriate next step? (5)
, Q3: 24 hrs after alteplase, the patient facial droop improved speech returned to
normal. L arm strength improved but leg strength diminished. L sided sensation
decreased. BP 132/78. Next step of mgmt? - correct answer-Q1: Noncontrast
computed tomography of the head. In addition to initial steps, it is good to do an
extensive neuro exam, serum glucose evaluation, O2 sat (try to maintain level >94%)
Q2:Alteplase and EKG. Thrombolytic should be given within 4.5 hours of symptom
onset. EKG evaluates for cardiac ischemia or a. fib. Labs: CBC, platelet count, PT,
PTT, BMP. Ok to have permissive HTN in order to ensure brain perfusion. Can use
IV labetalol if sys BP is >185. Start antithrombotic (ASA) and anti-lipid (statin) within
48 hrs of stroke
Q3: ASA, dysphagia evaluation, Echocardiogram, MRI of the brain, statin. Patient
should be admitted. MRI and echocardiogram used to confirm diagnosis of stroke
and determine underlying cause of stroke (embolism from cardiac source). CT again
to look for hemorrhagic conversion but only in hi risk. Common complication of
stroke is development of aspiration PNA due to undetected dysphagia.
63 yo male presents for routine visit, c/o L knee pain. Hx of contact sports (rugby,
football). Pain is deep, throbbing medial joint pain worse after active day. Recently
avoiding exercise, feels "old and worthless." Stiff in the am for 15 minutes, pain
interferes with sleep 3-4 nights/wk. No relief with acetaminophen and partial relief
from ibuprofen daily. No hx of CV, peptic ulcer dz, no current meds. HR 72, BP
118/80, RR 12, BMI 32kg/m2. PE: crepitus of L knee with passive movement,
decreased flexion on ROM, no knee pain with passive L hip motion. Mild swelling, LE
edema. ESR 12.
Q1: What action if any should be taken for patient at this time? (7)
Q2: Patient in discomfort. You encourage exercise, ROM and strengthening
exercises. Referred to nutritionist. He loses 20lbs BMI 30. Naproxen BID. SxS
improved, pt happy with increased ability to do activities, wakes up 2x from nocturnal
pain. What actions should be - correct answer-Q1: Educate patient on benefits of
exercise program, prescribe ROM and quads strengthening exercises, refer pt to
nutritionist for weight loss counseling
Q2: Intraarticular glucocorticoid injection o L knee, referral to orthopedic surgeon
Q3: referally to orthopedic surgeon for total knee arthroplasty
Q4: LMWH (alternatives can be warfarin or rivaroxaban), rehabilitation on day 1
49 yo male at urgent care with LBP (6 out of 10 pain) of 3 wks after lifting heavy
object at work. It is achy, sharp spasms with twist and bend. Located center and
36 yo F in ED with difficulty breathing. SOB for 24 hrs w/ mild CP with deep
inspiration and coughing w/o production. No fever. No LE edema, hx of CV
problems, or wt loss. No travel. Meds are norgestrel/ethinyl-estradiol. VSS. BMI
32kg/m2. PE: diaphoretic, CV norm, pul, with fine bibasilar rales.
Q1: What actions should be taken for this patient? (8)
Q2:ABG shows pH 7.45, pO2 90mmHg, pCO2 30mmHg. CXR shows elevated
diphragm. EGK sinus tachy. D-dimer 1.4ug/ml FEU, bhCG neg. HR 108, BP 118/70.
What action next? (4)
Q3: CTPA shows filling defects in R interlobar bulmonary arteries consistent with PE.
Pt is alert and conversant. HR 110, BP 114/68, RR 24, O2% 96. What action, if any,
should be next? - correct answer-Q1: D-dimer (with low pretest probability), but if
patient were to have a high pretest probability, skip D-dimer go to CTPA.
Q2: CTPA (ONLY do a VQ scan if CTPA is contraindicated in pregnancy or renal
insufficiency). No treatment initiated in hemodynamically stable patient since there is
bleeding risk. If unstable then its ok to treat.
Q3: Tx with enoxaparin. If patient is HDS choose anticoagulation therapy (LMWH >
UFH b/c they do not require PTT monitoring q 6hrs). If contraindicated, use IVC. If pt
is HD unstable (aka systolic BP <90 for >15 min) choose thrombolysis. If
contraindicated, emergent embolectomy.
Note: those with PE should be treated at least 3 months of outpatient
anticoagulation. Warfarin is good after heparin bridge. Other Xa inhibitors can be
used. After 3 months, ASA is used. Heme workup later would evaluate for deficiency
in antithrombin III, protein S and C, factor V leiden mutation, antiphospholipid
antibodies
67 yo F in ED. 1 hr ago, pt started having slurred speech and weakness in L arm and
leg. PMHx of 35 pack yr smoking. No current meds. T98.2, BP 180/104, HR 108, RR
19, O2% 98%. PE: anxious, unable to answer questions well, L side facial droop, 4/5
strength on left side, decreased sensation. No abnormal BG.
Q1: Single most important step? (2)
Q2: CT is unremarkable. What is the most appropriate next step? (5)
, Q3: 24 hrs after alteplase, the patient facial droop improved speech returned to
normal. L arm strength improved but leg strength diminished. L sided sensation
decreased. BP 132/78. Next step of mgmt? - correct answer-Q1: Noncontrast
computed tomography of the head. In addition to initial steps, it is good to do an
extensive neuro exam, serum glucose evaluation, O2 sat (try to maintain level >94%)
Q2:Alteplase and EKG. Thrombolytic should be given within 4.5 hours of symptom
onset. EKG evaluates for cardiac ischemia or a. fib. Labs: CBC, platelet count, PT,
PTT, BMP. Ok to have permissive HTN in order to ensure brain perfusion. Can use
IV labetalol if sys BP is >185. Start antithrombotic (ASA) and anti-lipid (statin) within
48 hrs of stroke
Q3: ASA, dysphagia evaluation, Echocardiogram, MRI of the brain, statin. Patient
should be admitted. MRI and echocardiogram used to confirm diagnosis of stroke
and determine underlying cause of stroke (embolism from cardiac source). CT again
to look for hemorrhagic conversion but only in hi risk. Common complication of
stroke is development of aspiration PNA due to undetected dysphagia.
63 yo male presents for routine visit, c/o L knee pain. Hx of contact sports (rugby,
football). Pain is deep, throbbing medial joint pain worse after active day. Recently
avoiding exercise, feels "old and worthless." Stiff in the am for 15 minutes, pain
interferes with sleep 3-4 nights/wk. No relief with acetaminophen and partial relief
from ibuprofen daily. No hx of CV, peptic ulcer dz, no current meds. HR 72, BP
118/80, RR 12, BMI 32kg/m2. PE: crepitus of L knee with passive movement,
decreased flexion on ROM, no knee pain with passive L hip motion. Mild swelling, LE
edema. ESR 12.
Q1: What action if any should be taken for patient at this time? (7)
Q2: Patient in discomfort. You encourage exercise, ROM and strengthening
exercises. Referred to nutritionist. He loses 20lbs BMI 30. Naproxen BID. SxS
improved, pt happy with increased ability to do activities, wakes up 2x from nocturnal
pain. What actions should be - correct answer-Q1: Educate patient on benefits of
exercise program, prescribe ROM and quads strengthening exercises, refer pt to
nutritionist for weight loss counseling
Q2: Intraarticular glucocorticoid injection o L knee, referral to orthopedic surgeon
Q3: referally to orthopedic surgeon for total knee arthroplasty
Q4: LMWH (alternatives can be warfarin or rivaroxaban), rehabilitation on day 1
49 yo male at urgent care with LBP (6 out of 10 pain) of 3 wks after lifting heavy
object at work. It is achy, sharp spasms with twist and bend. Located center and
