CCS Cases Notes-Raj

7/23/2019 CCS Cases Notes-Raj

1/21

CCS CASES

1. Office-25 yr old female with burning micturitionAbdomen and genital/pelvic exam

U/A and urine B-hcg.

Amox for 7 days if pregnant, !"-#$% for &day' if not pregnant, uncomplicated and(day' if not pregnant and complicated. )f penicillin allergic give' nitrofurantoin.

"renatal vitamin', regular follow up', 'tandard coun'el.

"yelonephriti'- O" oral *ipro-+day', )"- ) *eftriaxone-+day'.iagno'i' Acute *y'titi' uncomplicated.

2. Office-(5yr old male with forgetfulne''*omplete exam except brea't

*0* 13, bmp 13, LFTs (R, #4 13, !it "-#$ (R% fo&ic acid (R, * 'can head without

contra't 13.

onepeil oral, olanapine oral for p'ycho'i'.Ad!ance directi!es% no dri!ing% medica& a&ert "race&et, egular coun'el.

iagno'i' Alheimer6' dementia.

' 7- 89yr old male with 'evere che't pain"ul'e Oxy, oxygen inhalation cont., 7:; 'tat, cardiac monitor cont., bp monitor cont., )

acce'' 'tat,


2/21

iagno'i' "regnancy Antenatal *are.

5. Office-2?yr old male with 0"

*omplete phy'ical exam.*bc13, bmp13, 7'r13, 'tool for ova and para'ite'13, 'tool for wbc'13, 'tool */#13,

@='13, " "13.

*on'ent for the procedure, flexible 'igmoido'copy 'tat, and recta& "iopsy stat.@operamide oral cont., dicyclomine oral cont., me'alamine rectal cont., dietitian.

egular coun'el.

iagno'i' Ulcerative *oliti'.

6. Office-2?yr old male with 2mth abd.pain and altered bowel habit'.

*omplete phy'ical exam.*0* 13, bmp 13, 'tool for fat, wbc', */# and ova para'ite', F0BT% TS, and 7#.

@operamide oral cont., lacto'e free diet, high fiber diet, biofeedbacB 13 and regular coun'el.

iagno'i' )0#.

7. 7-85yr old male with 'evere breathle''ne''

Focused )E-#st 1

ead e&e!ation, pul'e Oxy 'tat, oxygen, cardiac monitor cont, ) acce'' 'tat, "7=

'tat>+h, =7+ 'tat>+h, 7:; 'tat, *$ "A lateral 'tat, AB2 stat.Albuterol nebulier cont., ipratropium nebulier cont., predni'one ) cont., levofloxacin oral

cont., *0* 'tat, bmp 'tat. )nterim h/o

#hift to ward, regdiet, am"u&ate at *i&&, urine output, vital' >h, /* cardiac monitor.

i'charge home with follow up 2wB', regular coun'el, !) Albuterol, !) )pratropium,Oral @evofloxacin, ome 0xygen therapy, 3nf&uen4a 5 )neumococca& 6accine.

iagno'i' Acute exacerbation of *O".

8. Office- 9yr old female with in'omnia, worthle'' and ea'y fatigability.

*omplete phy'ical exam.*bcC, bmpC, #4C, E28% 6it "-#$ and fo&ate8.

=luoxetine oral cont., 'uicide contract, regular coun'el.

iagno'i' !aDor epre''ion.

9. 7- 55yr old male with acute confu'ion, blurry vi'ion and headache.

=ocu'ed "7"ul'e Oxy 'tat, oxygen cont., ) acce'', cardiac monitor, bp monitor, and 7:; 'tat.

* head without contra't.

#od.


3/21

i'charge home lipid profile, regular coun'el.

iagno'i' 4yperten'ive 7ncephalopathy.

10. 7- (mth old child with 'evere on'et of 'udden breathle''ne''.

2enera&% &ungs% chest examn-#st

1"ul'e oxy 'tat, oxygen cont., ) acce'' 'tat, cardiac monitor, *$ "Alateral 'tat, 9ec: x-

ray &atera& stat, and *0* 'tat.

!ethylpredni'one ) onetime bolu', cefaolin ) onetime bolu', 0roncho'copy 'tat,"ulmonolgy con'ult.

iagno'i' =oreign body a'piration.

11. Office- 9yr old female with lump in left brea't.

*omplete phy'ical examn

!ammographyC, =2h,

0!" >h then >+2h then >+d, after hr' 'hift


4/21

precaution'.

iagno'i' 8h, continue home med', EC0 stat,

a'pirin oral cont., accuchecB' gluco'e >8h, cardiac monitor cont., carotid oppler 'tat.a'cular 'urgery con'ult 'tat. )f accepted pt, ptt, con'ent, blood grouping and typing.

iagno'i' )A.

15. 7-22yr old female with fever and pelvic pain.

=ocu'ed "7.

*0* 'tat, bmp 'tat, urine b-hcg 'tat, U/A */# 'tat, gram 'tain cervix 'tat, gonococcal

culture cervixC, chlamydial culture cervixC, 6;RL test8% 36 EL3SA8% )A) 8.Admit to floor, npo, vital' >h, bed re't with bp, iv acce'' 'tat,


5/21

18. Office- 28yr old female with amenorrhea and abdominal pain.

=ocu'ed "7.

Urine 0-hcg 'tat.Admit to floor, 2hJ ambulate at will, reg.diet, fre>uent examn.


6/21

fluid re'triction, weight', urine output, pneumatic compre''ion 'tocBing', continue home

med'., eBg repeat, bmp >+d, 4bA+c, lipid panel, accuchecB >8h, CL ora& cont, igoxin

oral cont., EC08.) to oral, reg.coun'el, follow-up in 2wB'.

iagno'i' *4=.

23. 7- (5yr old male with altered mental 'tatu' and decrea'ed urine output.

Comp&ete )E-#st 1

"ul'e oxy 'tat, ) acce'' 'tat, ) 2h, diabetic

renal diet, complete bed re't, urine output, compre''ion 'tocBing', weight', accuchecB' >8h,4bA+cC, 'liding 'cale in'ulin, U#; renalC.

) to oral, regular coun'el.

iagno'i' "re-renal Aotemia.

24. Office- +8yr old female with heavy men'trual bleeding.=ocu'ed "7.

Urine 0-hcgC, *0*C, " "C, 'erum #4C, serum pro&actinC, )ap smearC.

O*"' low e'trogen, low proge'terone, cont., oral iron 'ulfate cont., iron rich diet, reg.*oun'el.

iagno'i' y'functional Uterine 0leeding.

25. 7- +8nth old infant with runny no'e, mild cough

)u&se oxy stat- +'tK

=ocu'ed "7*ool humidified air, if not relieved oral or ) decametha'one.

iagno'i' iral *roup.

26. O"- 8mth old infant with vomiting and diarrhea.

=ocu'ed "7

) acce'' 'tat, ) 8h, 0!" next day, di'charge if

hydrated normal 0!".iagno'i' Acute ;a'troenteriti'.

27. 7- Eyr old female with fever, poor eating and abdominal pain.

=ocu'ed "7.

"ul'e oxy 'tat, ) acce'' 'tat, )


7/21

analge'ia onetime 'tat, 36 cefa4o&in 5 metronida4o&e stat.

iagno'i' Acute Appendiciti'.

28. O"- &mth old infant with runny no'e, poor eating low grade fever.

"ul'e oxy 'tat.=ocu'ed "7

Admit to floor, pul'e oxy >+h, cardiore'piratory monitor, A0; 'tat, *$ 'tat, umidifiedoxygen, ) h, EC0 stat, telemetry, /* oxygen,oral )ndomethacin cont.

i'charge home with reg. *oun'el.

iagno'i' Acute pericarditi'.

31. 7- 82yr old male with pain and 'welling of right lower extremity.

=ocu'ed "7."ul'e oxy 'tat, ) acce'' 'tat, ) +d, interim h/o phy'ical

>h, diabetic diet.) to oral, re'tart metformin, reg. coun'el, foot care, follow up in 2wB'.

32. 7- &yr old female with !A.


8/21

*ervical 'pine immobiliation, "ul'e oxy 'tat, oxygen cont., ) acce'' 'tat, ) 8h, #urgery con'ult 'tat.

/* cervical immobility, 'hift to floor, =oley catheter, pul'e oxy >h,


9/21

37. Office- +&yr old female with 'hort 'tature primary amenorrhea.*omplete "7

U/A13, 0U< *reatinine13, fa'ting blood 'ugar13, 'erum =#4 @413, :aryotype13,

follow up in +wB.U#; pelvi'13, 'erum #413, #Beletal 'urvey, Audiometry, 7*4O13.

;rowth hormone #* cont., ora& con?ugated estrogen cont., e'trogen replacement coun'el,

vit- oral cont., psychiatry consu&t% 0B2@9 consu&t, reg. coun'el.iagno'i' urner' #yndrome.

38. 7- 85yr old male with fever and 'evere @@N pain.=ocu'ed "7

"ul'e oxy, ) acce'', )


10/21

41. office- 29yr old female with hir'uti'm

*omplete "7

.rine B-hcg, 'erum te'to'terone free total, 'erum 47A-#, 2hr urine +(-Beto 'teroid',2hr urine corti'ol, =#4 @4, prolactin, #4, U#; "elvi', follow up after re'ult'.

Fasting &ipid profi&e, ;, "ap 'mear, O*"', reg. coun'el.

iagno'i' "*O.

42. Office- 52yr old female with 'leeple''ne''.*omplete "7

"ap 'mear, =a'ting lipid profile, !ammogram, flexible 'igmoido'copy, 7$A-#can, =O0.

4 oral cont., oral it- cont., Oral *alcium carbonate cont., reg. coun'el.

iagno'i' !enopau'e.

&.

44. Office- 55yr old male with fatigue.

*omplete "7

*0*C, 0!"C, #4C, =O0C, @='C.;) con'ult 'tat, *olono'copyC.

* abdomen che't with contra't, oral iron 'ulfate, CEA &e!e&, refer for colorectal 'urgery.

iagno'i' Adenocarcinoma of *olon.

45.


11/21

46. Office- &yr old male with facial and 'crotal 'welling.

*omplete "7

U/A 'tat, *0* 0!" 'tat, LFTs stat% )T 5 )TT stat% C' and C &e!e&s stat , lipid panel.Admit to floor, )/O, vital' >h, cardio re'piratory monitor, +h until 'table.

Admit to floor, +2h.

i'charge home with coun'el, 'creen for abu'e and dome'tic violence.iagno'i' *hild )ntoxication.

49. 7- 85yr old female with #O0 and che't pain.

"ul'e oxy, iv acce'' 'tat, oxygen cont., cardiac monitor cont., head e&e!ation% aspirin SL.

=ocu'ed "7.

7Bg 'tat, cxr pa 'tat, a"g stat, troponin-3 stat% c:-m" stat, pt and ptt 'tat, cbc 'tat, bmp 'tat,iv n' cont.

=obt 'tat, heparin iv cont., /N 'can, d-dimer stat.

Admit to icu, npo, bedre't, urine output, vital', pul'e oxy >2h, telemetry cont., cbc >+d, ">8h, interim h/o >h.

)v to oral, d/c monitor' and oxygen, warfarin oral cont., pt12 to &3 and platelet count.

i'charge with oral warfarin for +2mth', follow up in 2day', checB " level', /* heparinon 5thday, anticoagulation teaching, eg. coun'el.

iagno'i' "ulmonary emboli'm.


12/21

50. office- &yr old male with pain and 'welling of +'tmetatar'ophalyngeal Doint.

=ocu'ed "7

*bc 'tat, 0U< and creatinine 'tat, pt and ptt stat, 'erum uric acid13,


13/21

and ipratropium cont.

#piral * che't, broncho'copy, con'ult pulmonary medicine, cbcbmp >+d, continue

Oxygen.* abdomen and pelvi', "onescan% LFTs% )FTs% R3 of "rain *ith and *ithout contrast%serum Ca, *on'ult Oncology and radiation oncology, !) of albuterol and ipratropium,

high protein diet.iagno'i' 0ronchogenic *a with Ob'tructive "neumonia.

55. 7- 5yr old male with fever and chill'.

=ocu'ed "7.

)u&se oxy stat5=$h, ) acce'' 'tat, iv n' cont., npo except med'., ho&d ateno&o&, urine

output >2h, vital' >2h, complete bedre't, pneumatic compre''ion 'tocBing', head e&e!ation,cbc 'tat >+d, bmp 'tat >+d, u/a c/' 'tat, blood culture' 'tat, pt and ptt stat, phenergan iv

"+2h, reg.diet, cbc 'tat, cmp 'tat, cxr palateral

'tat, u/a 'tat, u'g abdomen 'tat, fobt 'tat, pt and pttC.

)aracentesis a"domen diagnostic% f&uid for ce&&s% protein% g&ucose% cyto&ogy, ct abdomen che't C, mammogramC, pap smear8% CA-#$ 8.

Obgyn and oncology con'ult.

iagno'i' Ovarian *a.

58. 7- 8&yr old nur'ing home re'ident with colicBy abdominal pain.=ocu'ed "7

)v acce'' 'tat,


14/21

gen.'urgery, di'charge home with follow up in +wB.

@ow fat diet, high fiber diet, patient coun'el.

iagno'i' #igmoid olvulu'.

59.7- 59yr old female po't chemotherapy with fever*omplete "7.

) acce'', continue lan'apraole, *0* 'tat, *!" 'tat, *$ "Alateral 'tat, blood culture'

'tat, U/A 'tat */#, 'putum for gram 'tain and */#, *eftaidime ) cont.Admit to ward, reg.diet, vital' >h, activity a' tolerated, regular interim h/o, cbc >+d,

acetaminophen oral "h, activity a' tolerated, urine output, pneumatic compre''ion'tocBing', cbc and bmp >+d.

iagno'i' Acute cholecy'titi'.

61. 7- &Eyr old male with fever and chill'

=ocu'ed "7.

"ul'e oxy 'tat, ) acce'' 'tat, ) h, vital' >h, urine output, pneumatic 'tocBing', advance clocBfor ?h, 77 'tat, *0* next day.

*on'ider 4) eli'a, 4b'Ag, antibodie' for 40* if not done before.

/* vancomycin, ) nafcillin cont. for to 8 wB', 36 centra& &ine p&acement(R, blood

culture' >+d till 'terile, examn next day.egular coun'el, gentamicin /* after 5day', followup in +wB, #07 prophylaxi'.

iagno'i' !##A t.'ided )7.

62. office- 89yr old female with irregularly irregular pul'e.

=ocu'ed "7."ul'e oxy 'tat, ) acce'' 'tat, 7:; 'tat.

36 di&tia4em "o&us, cbc 'tat, bmp 'tat, *$ "A lateral 'tat, C-B 5 troponin-3 stat=>h, U/A 'tat, #4 'tat, free 13, @=' 'tat, " " 'tat.

Admit to floor, pul'e oxy >h, vital' >h, telemetry cont., 0L; records, carbohydrate diet,


15/21

bedre't with bp, 4bA+c 'tat, accuchecB' N), $;-EC0 (R, continue all home med', )

diltiaem cont., ) heparin cont., " >8h, cbc >+d.

Urine */# 'tat, !"-#$% oral for &day'.)nterim h/o in 2h, telemetry monitor, eBg repeat, interim h/o in 8h telemetry. Once 4 Q?9

'top ) diltiaem and 'tart oral diltiaem, oral warfarin cont., " daily

*hecB cbc, telemetry, " next day. )f " 2 to & 'top heparin and di'charge.=ollow up in &day' for "7, *0*, " and platelet count.

iagno'i' A=

63. 7- 8+yr old man with 'evere che't pain after !A.

) acce'' 'tat, pul'e oxy 'tat, oxygen cont., general, heart, lung' examn.

) 2h, pneumatic

'tocBing', foley catheter, )


16/21

=ocu'ed "7.

*0* 'tat, 0!" 'tat, @=' 'tat, " " 'tat, 7:; 'tat, 36 pantapro4o&e cont., blood

grouping typing 'tat,


17/21

70. 7- ?9yr old male with fatigue and UN pain.

)u&se oxy stat% 36 access stat% oxygen cont-#st 1

=ocu'ed "7

*0* 0!" 'tat, 7:; 'tat, *$ "A lateral 'tat, serum Lipase stat, @=' 'tat.Admit to floor, blood culture' 'tat, ) @evofloxacin cont., acetaminophen oral cont., vital'

>h, pul'e oxy >2h, bed re't with 0", pneumatic compre''ion', diabetic diet, oral clear',

accuchecB' >8h, influena pneumococcal vaccine, continue oral glipiide, interim h/o after+2h, *0* after +day.

i'charge with reg. *oun'el.

iagno'i' "neumonia- *ommunity ac>uired.

71. office- &2yr old male with fever, fatigue and dry cough.

*omplete "7

*0*C, 0U< *reatinineC, *$ "A lateralC, 7#C, 7:;C, #putum for gram 'tain A=0C, #putum for */#.

@='C, 'erum uric acidC, Ophthalmology con'ultC.Oral )8h, bedre't with 0", reg.diet.h.

*$ decubitu' film', )T 5 )TT8, Anti-d'


18/21

7.

75. 7- 2?yr old female with 'udden on'et of #O0 facial 'welling.

"ul'e oxy 'tat, oxygen cont., ) acce'' 'tat, )


19/21

=ocu'ed "7

) acce'' 'tat, ) Betorolac 'tat, *0* 0!" 'tat, 'erum *a 'tat, $-ray @umbo'acral 'pine,

7#C, interim h/o.#"7"C, TS8% ora& naproxen cont., Oral it- cont, Oral *alcium carbonate cont., 0ra&A&endronate cont., calcium rich diet, reg.coun'el, di'charge home, follow up in & to (day'.

"hy'ical examn, 7$A 'canC.iagno'i' O'teoporotic ertebral *ompre''ion =racture.

79. 7- 22yr old female with fever, chill', myalgia' and headache'.

) acce'' 'tat, pul'e oxy 'tat, cardiac monitor cont., 0" monitor cont., )


20/21

iagno'i' emporal Arteriti'.

83. office- 5&yr old male with fatigue, con'tipation, cold intolerance, impaired 'leep.

*omplete "7

*0* 0!"C, #4C, =O0 'tat, 7:; 'tat.=ree C, @ipid "anelC, low fat diet, oral @evo-thyroxine cont., ora& 6it-; cont% ora&

Ca&cium car"onate cont.

egular coun'el, follow up in +wB.=ollow up in 8wB' with #4.

iagno'i' "rimary 4ypothyroidi'm.

84. )npatient- (9yr old male with fever and chill'

"ul'e oxy 'tat, ) acce'' 'tat.

=ocu'ed "7

)


21/21

abdomen acute 'erie' 'tat, U#; Abdomen 'tat, ) !orphine 'tat bolu', ) "henergan 'tat

bolu'.

"ediatric #urgery con'ult 'tat, 0arium enema 'tat.#hift to floor, bed re't, urine output, vital' >h, /* all ), oral clear', /* after 2hr'.

iagno'i' )ntu''u'ception.

88. office- &yr old male with na'al di'charge, conge'tion, facial and cough.

=ocu'ed "7Oral amoxicillin cont for ( to +9day', oral acetaminophen cont., oral p'eudoephedrine cont.,

cool humidified air, diet full li>uid'.

iagno'i' Acute #inu'iti'.

CCS Cases Notes-Raj

Documents

Transcript of CCS Cases Notes-Raj