oral boards

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oral boards
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  1. Overdose (Iron)
    22y/o female via EMS for NVD p intentional overdose
    • Large bore IV access and fluid bolus
    • EKG
    • Whole bowel irrigation
    • Deferoxamine 5mg/kg/hr IV-->15mg/kg/hr NTE 6gm/day
    • FSG: ferrous fumurate 33%, sulfate 20%, gluconate 12%
    • Toxic: 300-500mcg/dl or as low as 10-20mg/kg elemental
  2. Vomiting Infant (Pyloric Stenosis)
    • iv access and adequate hydration
    • abdominal examination: peristaltic waves, "olive" sign
    • ng tube, NPO
    • abdominal US
  3. AMS(nontraumatic intrancranial hemorrhage)
    • Checking ETT placement upon arrival
    • large-bore IV access and fluids
    • lab eval (coag factors)
    • head CT for new onset coma
    • reversal for anticoagulation
    • neurosurg consult, ICU consult
    • finger stick glucose
  4. COMA
    • bilateral hemispheric pathology or damage to reticular activating system
    • causes: trauma,infarction or hemorrhage; central venous thrombosis, meningitis, hydrocephalus, malignancy, cerebral abscess, toxic overdose hepatic or renal failure, sepsis and metabolic abnl's, CO poisoning
    • Cushing's Reflex: bradycardia and hypertension (inc ICP)
  5. Chest Trauma (Tension Pneumo)
    • Needle thoracostomy-->tube thoracostomy
    • upright CXR
    • pain management-->surgical consult
  6. Abdominal Pain and Vomiting (Cholecystitis)
    • large bore IV access
    • RUQ US
    • pain management, surgery consult, abx (eg. amp/sulbactam)
  7. Weak Infant (Sepsis)
    • iv or io access and multiple fluid boluses
    • early abx
    • ICU consult
  8. Chest Pain (Borhaave's Syndrome)
    • Note crepitus on physical exam
    • Consider esophageal tear in chest pain ddx
    • CXR to evaluate lungs and mediastinum
    • STAT GI and ENT consults to determine etiology of pneumomediastinum.
    • CT Surgery consult for potential operation.
    • Resuscitative fluids and abx for mediastinitis.
  9. Back Pain (Epidural Abscess)
    • Consider dx in person w/back pain and fever.
    • Obtain rectal temperature.
    • Obtain stat imaging.
    • Neurosurgery consult.
    • Determine cause:  UTI (hx urinary retention).
  10. Leg Swelling (Necrotizing Fasciitis)
    • Early recognition d/t appearance,rapidity of sx development, pain and possible sepsis.
    • Aggressive resuscitation w/ IV fluids.
    • IV abx.
    • Immediate Surgical consult.
    • Do not allow delay of operative intervention.
    • Avoid vasopressors if possible.  Lower extrems most common site follwed by upper extremities.
  11. Weakness (Hyperkalemia)
    • Obtain EKG
    • Note hyperkalemia (ekg or labs)
    • Immediate stabilization w/calcium
    • Meds to shift potassium and decrease total body potassium
    • Admission
  12. Eye Pain (Acute angle-closure glaucoma)
    • Thorough eye exam including including visual acuity, intraoccular pressure and slit lamp.
    • Early administration of glaucoma meds: Brimonidine (or other alpha agonist), Timolol, Acetazolamide (contraindicated in sickle cell dz), Mannitol, Prednisolone, Pilocarpine.
    • Emergent Ophthalmology consult.
  13. Abdominal Pain ( Incarcerated hernia with obstruction)
    • Recognition of hernia
    • large bore IV access and fluid bolus
    • AAS
    • NGT placement
    • Pain Management
    • Surgery Consult
  14. Ringing in Ears (Salicylate toxicity) 17y/o female
    • Large bore IV access
    • Pregnancy Test
    • Hx salicylate use
    • Alkalinization on urine with sodium bicarb.
    • Close monitoring of pt and salicylate levels.
    • ICU admission
  15. Vomiting child (Henock-Schonlein Purpura)
    6y/o boy
    • Fluid resuscitation
    • AAS
    • Pain management
    • Labs for liver and renal injury
    • Surgery Consult (hematemesis/blood diarrhea)
  16. Snake Bite (python) 7y/o (acting nl p 1 hr)
    • Assess ABCs
    • Assess wound
    • Identify snake for risk of venom exposure
    • Thorough hx and physical--total exposure
    • Poison Control Center
  17. Visual Impairment (Retinal Vascular Occlusion)
    • Ocular Exam:  Optic disc edema and diffuse retinal hemorrhages in all quadrants.  Marcus Gunn Pupil if complete occlusion.
    • Ophthalmology Consult
  18. Syncope (11y/o female with 2 episodes p exercise) Torsades
    • EKG: prolonged QT
    • Recognition of Torsades after pt decompensates
    • Resuscitation per PALS guidelines (magnesium and defib).
    • Cardiology consult
  19. Retropharyngeal Abscess ( 3y/o male w/ fever,drooling,sorethroat)
    • Airway cart, prep for intubation
    • Soft tissue Neck xray
    • ENT Consult
    • Abx
    • ICU admission
  20. SCFE (15 y/o obese male w/ left knee pain and limp)
    • Physical Exam of both hips
    • Bilateral hip xrays w/lateral views
    • Ortho Consult for SCFE
    • Pain meds and non-weight-bearing
  21. Testicular Torsion (3y/o w/abd pain and new "diaper rash")
    • Testicular exam
    • Immediate Urology consult/pediatric surgery consult
    • Testicular US
    • Pain Management, NPO
    • Manual detorsion attempt
    • OR for surgical exploration and detorsion
  22. Gastric Perforation (79y/o fem w/abd pain)
    • Large bore iv access and fluid bolus
    • Upright chest xray (AAS)
    • Pain management
    • Surgery consult
  23. Pertussis (1y/o male w/ cough paroxysms)
    • Oxygen
    • Saline for tachycardia
    • CXR
    • Abx for patient AND close contacts
    • Admit to respiratory isolation
  24. AAA (77 y/o male w/flank pain)
    • Large bore iv and fluid bolus
    • Bedside US
    • Surgery Consult
    • Blood transfusion (10-16 units pRBCs and FFP available)
    • Grey-Turner's = retroperitoneal hemorrhage
  25. Carbon Monoxide Poisoning (68y/o female w/lethargy and depression (cat died night before))
    • 100% NRB mask
    • FS glucose
    • Obtain hx c/w CO poisoning
    • Obtain COHb level
    • Transfer to hyperbaric treatment facility
  26. Maxillofacial Trauma (Assault to Face, LeFort II Fracture)
    hx baseball bat to face w/epistaxis
    • Early airway control using advanced airway technique w/ cricothyrotomy set up simultaneously
    • Hemorrhage control (pressure to nose/packing)
    • C-spine immobilization
    • CT: head, c-spine, face
    • Trauma consult/Oral Maxillofacial Surgery (OMFS)
  27. Burn (24y/o male fell in the fire, EtOH) face/mouth burned
    • Large bore IV and fluid resuscit (Parkland formula)
    • Analgesia
    • Intubation
    • Escharotomy for 3d degree circumferential burn to extremity
    • Tetanus administrationj
    • Transfer to Burn Unit
  28. Vomiting Blood (37y/o female alcoholic) Variceal Bleeding
    • Large bore IV access
    • Hemodynamic monitoring
    • Blood, platelets, FFP transfusion
    • GI consult (EGD)
    • ICU admit
    • vasopressin, octreotide, esomeprazole
  29. Light-headedness (87y/o female) Sinus Bradycardia
    • EKG, O2 sat
    • Atropine
    • Pacing  (transcut or transvenous)
    • Cardiology consult
    • ICU admit
    • glucagon for metoprolol overmedication
  30. Status Asthmaticus (37 y/o obese male with resp distress)
    Shortness of Breath
    • Pulse-Ox, Cardiac monitoring
    • Supplemental O2
    • Albuterol, Solumedrol, Atrovent
    • Frequent reassessment (peak flows, p-ox,resp effort)
    • Adjunctive tx prn (magnesium, epi, BiPap)
    • ICU admit
  31. Rash and Fever
    27y/o w/Rash and Fever
    Stevens-Johnson Syndrome (Erythema Multiforme Major)
    • Obtain history of recent abx use
    • Skin Exam (target lesions), mucocutaneous lesions (oral and vaginal)
    • Establish dx of Erythema multiforme major
    • Derm consult
    • ICU admission (Burn unit)
  32. Weakness (Guillain-Barre syndrome)
    67 y/o male w/ascending weakness
    • Finger stick glucose
    • Thorough neuro exam--> dx of GBS
    • Neurology consult
    • Recognize worsening respiratory status-->intubate electively
    • Admit to ICU
    • Begin plasma exchange or IV immunoglobulin
    • Avoid succinylcholine as paralytic-->hyperK
  33. Abdominal Pain w/Vomiting:  Small Bowel Obstruction
    51 y/o female (hx prior abd surgeries)
    • IV access and fluids
    • AAS
    • Pain management
    • Surgery consult
    • NG tube
  34. Chest Pain:  Cocaine induced chest pain
    37y/o male
    • EKG and monitor, O2 administration
    • Benzodiazepines
    • Pain management prn (nitrates and morphine)
    • Cardiac enzymes
    • CXR
    • Admit to Obs to eval for cardiac ischemia
  35. Seizure:  Simple febrile seizure
    34m/o male w/generalized seizing
    • Detailed H&P to assess for meningitis or other obvious bacterial infection
    • APAP Q4H or ibuprofen Q6H to reduce fever
    • Counsel parents re simple febrile seizures and f/u

    • note: pt discharged home in book answer, no LP, no CT
    • LP recommended for children under 12 months or focal, toxic, not playful after p ictal period, or concern w/ f/u or pt already on abx.
  36. Chest Pain:  PE
    45 y/o female s/p left ankle surgery x 2 weeks
    • EKG, CXR, VQ scan or chest CT angio
    • Heparin: unfractionated IV, or low molecular weight IM
    • admit for anticoagulation
    • Consider thrombolysis (alteplase) w/cardiorespiratory collapse d/t PE
  37. Throat Swelling:  Anaphylaxis
    5 y/o w/peanut allergy
    • Airway assessment
    • O2, epi, and benadryl or hydroxyzine
    • NS (20cc/kg) bolus IV
    • Obs for at least 6 hours
    • If discharged, rx for epi autoinjector, benadryl and avoid allergic trigger
  38. Abdominal Pain (Appendicitis)
    24 y/o female
    • Urine pregnancy test, UA
    • Pelvic exam in woman of child-bearing age
    • Pain management
    • Abx pre-operatively, Serial abdominal exams
    • CT abdomen/pelvis with enteric (rectal) contrast
    • Surgery Consult
    • US possible if pregnant
  39. Altered Mental Status (Subdural Hematoma w/midline shift)
    85 y/o male w/disorientation
    • Early finger stick blood glucose
    • Obtain hx recent fall
    • Noncontrast head CT, lab evaluation
    • Pain mgt, no NSAIDs which could worsen bleed
    • Neurosurgery consult
    • ICU admit
  40. Rectal Pain, Uncomplicated Perianal Abscess
    28 y/o male with pain in anal region
    • Pain meds
    • Thorough exam to r/o sx fistula or systemic involvement
    • I&D
    • Discuss p I&D mgt: sitz baths, stool softeners, drsg changes
    • Arrange f/u
  41. Vag Bleed (Ectopic Pregnancy)
    25 y/o female w/abdominal pain and vaginal bleeding
    • Large bore IV access and fluid bolus
    • Blood type & cross
    • HCG
    • Rho (D) immune globulin IM
    • Pelvic exam, pelvic US
    • Pain management
    • OB-Gyn consult
  42. Agitation (Alcohol intoxication)
    49y/o male with agitation
    • Finger stick glucose
    • Noncontrast Head CT
    • Anion gap, osmolar gap
    • Lac repair
  43. Abdominal Pain (DKA, UTI)
    45 y/o female w/abdominal pain and fever
    • Early blood glucose assessment
    • Fluid replacement NS
    • Insulin drip
    • Replete potassium (nl but will drop with insulin)
    • EKG
    • ICU admission, abx for UTI
  44. Abdominal Pain (Inferior wall MI w/ right ventricular involvement)
    61 y/o male w/epigastric pain and nausea
    • EKG, right-sided EKG
    • IV access and fluid bolus
    • ASA administration, avoid NTG administration
    • Cardiology consult
    • Activating cardiac cath lab
  45. Abdominal Pain (Ovarian Torsion)
    25 y/o female with abdominal pain
    • Pregnancy test
    • Pelvic exam
    • Pelvic US
    • OB-Gyn consult for laparoscopy and detorsion
    • Analgesia
  46. Altered Mental Status (Opiod OD)
    33 y/o male found unconscious
    • Finger stick glucose (DONT protocol)
    • Naloxone administration
    • EKG, CXR
    • Reassessment after interventions

    Naloxone 2mg, may repeat Q3min until 10mg given
  47. Diarrhea (Traveler's Diarrhea)
    34 y/o male w/abdominal pain and diarrhea
    • Elicit social hx: travel, risk factors for immune compromise, recent abx
    • Stool sample for O&P, fecal leuk's,Giardia antigen/C.diff
    • Rehydrate and replete electrolyte deficiencies
    • Prescribe abx (metronidazole, cipro or albendazole) x 5d
    • Arrange for f/u
  48. Seizure (Thrombotic thrombocytopenic purpura)
    45 y/o male w/seizure
    • Note petechiae on physical exam
    • Obtain CBC
    • Steroids
    • Plasmaphoresis
    • Heme consult (noting possible TTP)
    • Admission
  49. Toothache (Ludwig's Angina)
    36 y/o male with infected tooth
    • Airway mgt, prep for difficult airway
    • Abx
    • ENT Consult
    • Admission
  50. Penetrating Chest Trauma, Acute Pericardial Tamponade
    24 y/o male stabbed in chest
    • Intubating patient for airway protection
    • Large volume fluid immediately
    • Dx'ing tamponade (Beck's triad: JVD, muffled heart sounds and hypotension), or performing US/thoracotomy
    • Starting blood transfusion
    • Surgical Consult for emergent OR repair
  51. Animal Bite
    35 y/o male w/cat bite 4 hr pta
    • Appropriate abx
    • Tetanus immunization
    • f/u for wound check
  52. Abdominal Pain, TOA (2/2 STD)
    24 y/o female w/lower abd pain x 4 days
    • Urine pregnancy test
    • GU exam
    • Pelvic US
    • Abx
    • Gyn consult
    • Pain meds
  53. Headache, Cavernous sinus thrombosis
    55 y/o male brought in by wife w/ worsening headache, fever, and eye pain x 2 days
    • Early abx and steroids
    • LP
    • MRI for dx
    • ICU
  54. Fever, Kawasaki's
    20 m/o male w/fever x 5 days, rash x 1 day
    • ASA (100mg/kg/day divided Q6H and IVIG (2gm/kg IV over 8-12 hours)
    • consult infectious disease or pediatric rheum
    • d/w family/PCP re dx and management
    • thrombocytosis (plt > 650k) a/w coronary artery thrombosis
  55. Back Pain, Cauda Equina Syndrome (from disc herniation)
    42 y/o male w/back pain and RLE pain s/p fall x 1 month
    • Pain control
    • Complete neurological examination
    • MRI
    • Neurosurg consult for decompression surgery
    • Dexamethasone (controversial) for edema
  56. Cardiac Arrest, SIDS
    7 m/o male brought in mom and EMS, found unresponsive
    • Initiate appropriate PALS life support
    • Assess for signs of abuse
    • Resuscitate and ensure temp in WNL before pronouncement of death.
    • Provide psychosocial support to family
  57. Knee pain, Septic Arthritis
    54 y/o female w/r.knee pain and swelling x 2 days
    • Knee arthrocentesis (informed consent, timeout, etc)
    • Ortho consult: possible joint irrigation in OR
    • Admit for iv abx
    • Abx: nafcillin or vancomycin if MRSA suspect
  58. Rash, Rocky Mountain Spotted Fever
    14 y/o male w/rash,fever, abdominal pain w/vomiting and diarrhea x 2 days, 1 day hx of rash
    • Obtaining travel hx--camping
    • Examination of rash
    • CBC, BMP, LFT
    • Complete physical exam including chest, lungs, abdomen, and neurological exam
    • Abx (doxycycline or chloramphenicol)
    • Consider co-infection w/other tickborne dz's: Lyme, Ehrlichiosis, babesiosis
  59. Sickle Cell Disease: Acute Chest Syndrome
    18 y/o male w/left shoulder and left-sided chest pain x 3 days
    • Oxygen
    • CXR and identification of pulmonary infiltrate
    • Pain control w/ IV opiate
    • Abx
    • Exchange transfusion or heme consult
    • Admission to medical ICU
  60. Headache, Bacterial Meningitis
    22 y/o male w/fever and headache
    • Appropriate abx tx BEFORE imaging or lumbar puncture
    • LP
    • Admission to isolation bed and ICU
    • Assessment of public health concerns (roommates, close contacts, etc).
  61. Chest Pain, Pericarditis
    34 y/o male w/chest pain (recent URI)
    • EKG
    • Cardiac examination
    • Echocardiogram
    • NSAID
    • Admission
  62. AMS, Hypoglycemia 2/2 sulfonylurea
    73 y/o female w/confusion and facial droop, garbled speech
    • IV access
    • finger stick glucose
    • iv dextrose
    • Further antihypoglycemic intervention (feeding, octreotide, dextrose fluids)
    • Admission
  63. Headache, High Altitude Cerebral Edema
    42 y/o skier w/ headache, nausea and "flu like sx" x 1 day
    • Head CT
    • Tx w/dexamethasone
    • hyperbaric chamber temporizes
    • Rapid descent (transfer to lower facility)
    • Oxygen
  64. AMS, Digoxin toxicity
    79 y/o w/AMS, nausea, weakness "things have yellowish hue"
    • EKG
    • Digibind
    • Treatment for hyperkalemia (NO CALCIUM!!!)
    • CCU
    • Atropine or pacer pads for bradycardia
  65. SOB, CHF Exacerbation
    82 y/o female w/ sudden onset sob x 30 min
    • High-dose ntg drip initiated
    • Furosemide
    • Oxygen
    • Aspirin
    • CCU consult
    • Admit CCU
  66. SOB, Critical aortic coarctation
    10 d/o male w/sob,"tiring out while feeding, sleeps a lot"
    • Recognize respiratory distress
    • Oxygen administration, intubation
    • IV access, EKG, CXR
    • Recognize cardiomegaly and cardiac etio of resp distress
    • Cardiology consult
    • Prostaglandin administration
  67. Flank Pain, Kidney stone
    30 y/o male with flank pain for 2 days, taking Vit A and Vit C
    • Large bore IV access and hydration w/more than 1L NS
    • Early pain control
    • Confirmation of dx of renal colic with CT (1st episode)
    • UA
    • Temperature
  68. Seizure,  Status Epilepticus (2/2 alcohol withdrawal)
    45 y/o male via EMS seizing despite IM Lorazepam
    • Finger stick glucose
    • IV access
    • IV benzodiazepine (until at least Lorazepam 8mg iv given)
    • Head CT
    • Labs and serum/urine tox
    • Neuro consult for new onset seizure/status epilepticus
  69. Fever, Fournier's Gangrene
    70 y/o demented male from NH w/ fever
    • Full exam for source of fever
    • Adequate fluid resuscitation
    • Emergency surgical consult
    • Broad spectrum abx
  70. Vomiting, Intussusception
    7 m/o male w/abd pain and vomiting
    • NS bolus 20ml/kg
    • Complete physical exam
    • Barium enema
    • Peds surgical consult
  71. Fever, HIV Pneumonia (likely PCP)
    45 y/o male w/fever and cough
    • Oxygen supplementation
    • IV fluids
    • CXR, UA
    • Abx
    • Respiratory isolation
  72. Palpitations, SVT
    39 y/o female w/hx HTN brought in by EMS w/palpitations
    • Large bore iv access
    • EKG
    • Discussion re side effects of adenosine
    • Adenosine w/rhythm strip (repeated)
    • Repeat EKG and vitals after breaking rhythm
  73. Cough, Community Acquired Pneumonia
    45 y/o female w/ sob, cough and fever
    • iv access
    • NS fluid bolus > 2L
    • CXR
    • Abx
    • Admission
  74. Drowning, C-spine fx and Neurogenic Shock
    27 y/o male via EMS after diving into shallow end, + LOC
    • Large bore iv access
    • C-spine precautions
    • CT c-spine
    • Neurosurg consult
    • Intubation (C-4 burst fx)
    • Pressors for neurogenic shock
  75. Abdominal Pain, Pancreatitis
    54 y/o male alcoholic w/severe epigastric pain
    • 2L NS bolus iv
    • type and hold
    • pain medications: opiates
    • discussion w/pt re alcohol cessation
  76. Abdominal Pain, Ischemic Bowel (embolus to Sup Mes a.)
    84 y/o female w/intermittent crampy abd pain and diarrhea
    • NS 2L bolus
    • CT abd/pelvis w/contrast
    • Abx
    • Surgery consult or interventional radiology consult
    • Pain medication
  77. SOB, COPD Exacerbation
    59 y/o w/hx COPD via EMS for severe respiratory distress
    • O2 Supplementation
    • B-agonist and anticholinergicd tx via nebulizer
    • Steroids
    • CXR
    • BiPap or CPAP or intubation
  78. AMS, Alcohol Withdrawal Seizures
    48 y/o male via EMS found on sidewalk unresponsive
    • Benzo's until seizure stops
    • FS glucose
    • Head CT
    • Management of agitated pt (haldol, ativan, physical restraints)
  79. Weakness, Left MCA Stroke (ischemic)
    66 y/o male w/sudden onset r.sided paralysis and slurred speech
    • finger stick glucose
    • head CT
    • Neurology/stroke team notification/consultation
    • Neurological exam
    • BP control with IV agents
  80. Pedestrian Struck, Pelvic Fx w/ hemorrhage, Open r.ankle fx
    57y/o female via EMS
    • large bore iv access x 2
    • blood transfusion
    • immediate activation of surgery/trauma service
    • FAST exam, chest and pelvic xrays
    • reduction and fixation of pelvis
    • interventional radiology for emergent embolization
  81. Back Pain, Pyelonephritis
    29y/o female w/back pain (fever x 3d)
    • Pain Control
    • Urine pregnancy test
    • iv fluids
    • abx
    • ensuring proper outpatient tx, instructions and f/u
  82. AMS,  Thyrotoxicosis, Pneumonia
    39y/o female via EMS memory loss, confusion,frank psychosis
    • NS fluid bolus, 1L
    • Finger stick glucose, CXR
    • Abx for possible meningitis
    • CT & LP for r/o CNS pathology
    • Serum tox
    • Propranolol, PTU, and Iodine
    • ICU consult/admit
  83. Abdominal Pain, Nonaccidental Trauma, Splenic Laceration
    3y/o male via mom: abd pain after falling off stool
    • Recognition of potentially serious abdominal injury
    • CT abdomen
    • Recognition of inconsistent story, possible abuse
    • Surgery Consult
    • Social work/child services consult
  84. Abdominal Pain, Hemolytic Uremic Syndrome
    5y/o boy w/mild abdominal pain, cola-colored urine & diarrhea
    • cbc: plt count 35, helmet and burr cells
    • large bore iv access and fluid bolus
    • discussion with family
    • admission
    • Peds hematology consult (possible plasmaphoresis if worse)
    • Nephrology consult
  85. Respiratory Distress, FOB Aspiration
    2 y/o with respiratory D
    • Airway management prep
    • Oxygen supplementation
    • CXR (inspiration and expiration)
    • ENT consult
  86. Overdose, Acetaminophen overdose
    45y/o female w/foot pain and depression (50 oxycodone tabs)
    • Determine timing of ingestion
    • check APAP level AND likely coingested substances
    • start NAC immediately based on calculated dose (>140mg/kg)
    • check EKG
    • Place patient on suicide watch
  87. chest pain, anterolateral MI
    59 y/o male w/chest pain
    • cardiac monitoring
    • ekg w/in 10 minutes of arrival
    • cardiology cath consult
    • aspirin
    • pain control w/morphine and/or nitroglycerine
  88. Fever,SIRS d/t pneumonia
    89y/o female via EMS from NH for fever and AMS
    • large bore iv access and fluid bolus
    • lactate
    • CBC, blood cx, urine cx, CXR
    • eval for sources of fever including cellulitis, decub ulcers, UTI
    • early abx or initiate EGDT if pt decompensates
  89. AMS, Heatstroke
    81y/o female via EMS from home: lying by bed in very warm apartment
    • check blood glucose
    • large bore iv access and fluid bolus
    • immediate cooling
    • core temp monitor
    • CT head
    • ICU admission
  90. SOB,Pericardial tamponade
    56y/o male from renal clinic w/lowBP, sob and dizziness
    • large bore iv access and fluid bolus
    • CXR,EKG
    • bedside cardiac echo
    • cardiothoracis surgery consult
  91. Stab to chest, Tension Pneumothorax
    53y/o female w/stab to chest and dyspnea
    • Emergent decompression (tube or needle followed by tube)
    • FAST exam
    • pain management
    • CXR to confirm tube placement
  92. Abdominal Pain, Diverticulitis with fever
    50y/o female with lower abd pain
    • Pelvic exam
    • Urine pregnancy test
    • Pain management
    • CT abd/pelvis w/iv and po contrast
    • Early surgery consult
    • Abx
  93. Seizure, Eclampsia
    42y/o female 7 days postpartum
    • large bore iv access
    • magnesium iv infusion
    • CT head
    • emergency obstetric consultation
    • UA
  94. Palpitations, Ventricular tachycardia
    59y/o male woke from sleep at 5am w/palpitations and SOB
    • 12 lead EKG
    • Amiodarone 150mg bolusees then drip when stable
    • Synchronized cardioversion (100J monophasic or equivalent biphasic equivalent) for instability(ams, low bp, or chest pain)
    • Cardiology consult, CCU admission
  95. Seizure, TCA overdose
    28y/o female
    • large bore iv access and fluid bolus (vasopressors prn)
    • EKG, repeat EKG after treatment
    • Sodium bicarb
    • Administration of activated charcoal
    • Medical ICU
  96. Fever, Post liver transplant fever
    66y/o male w/fever and abd pain, s/p liver transplant
    • large bore iv access and fluid bolus
    • cultures before abx
    • Paracentesis w/fluid analysis and cx
    • Broad spectrum abx
    • Pain meds
    • Contact appropriate consultant (transplant team)
    • Reverse isolation hospital bed/ICU
  97. Abdominal trauma,Blunt abd trauma--splenic rupture
    46y/o male s/p MVA (bent steering wheel)
    • large bore iv access and fluid bolus
    • blood type and cross-match
    • pain control
    • trauma surgery or general surgery
    • FAST exam
    • early pRBC transfusion w/destabilization of vital signs
    • advocate for laparotomy when patient decomps
  98. Hematochezia, Necrotizing enterocolitis
    20 d/o male w/poor feeding and blood in diaper
    • iv access and fluid bolus
    • abd xray AP and lateral decub (pneumointestinalis)  +/- US
    • cultures/abx to r/o sepsis
    • peds surgery consult
  99. Abdominal pain, Spontaneous bacterial peritonitis
    68y/o male w/ worsening abd pain x 2 d, hx cirrhosis
    • iv access and fluid bolus
    • early paracentesis
    • early abx
    • pain management
  100. Cough, Pulmonary inhalation anthrax
    42y/o male (alpaca farmer)
    • CXR
    • Early abx (pcn, doxycycline, erythromycin, cipro)
    • Intubation, Isolation
    • MICU admission
    • Call CDC
    • Prophylax healthcare workers and family (cipro)
  101. Headache, Hypertensive Emergency
    56y/o male w/headache (sudden onset), hx htn and ran out of meds 235/128
    • iv antihypertensive medicine
    • pain control
    • head CT, LP
    • Admission
  102. Drowning, Hypothermnia 2/2 cold-water immersion
    15y/o female, fell into partially frozen lake
    • Airway management
    • Undressing patient and assessing for sx trauma
    • Temperature monitoring w/rectal probe
    • Aggressive warming (fluids,bair hugger, lavage, foley)
    • PICU consult
  103. Cyanosis, Aortic coarctation
    12 d/o male with episode of turning blue in the face
    • Supplemental oxygen
    • Listen to anterior chest AND BACK for murmurs
    • CXR
    • Prostaglandin E1
    • Discuss condition w/family
    • Cardiology consult
  104. Diarrhea, Enteroinvasive diarrhea
    33 y/o male w/bloody diarrhea x 2 d
    • Rehydration
    • Repletion of electrolytes
    • Abx: cipro
  105. Cough, Pneumocystis Pneumonia (PCP)
    59y/o male from prison w/productive cough and SOB
    • CXR
    • Airway management--oxygen
    • Abx for CAP and PCP (Rocephin, Azithro, Septra)
    • Airborne isolation
    • MICU consult
  106. AMS, INH Overdose
    63y/o homeless male found on shelter floor
    • Airway management
    • Glucose
    • Pyridoxine administration
    • Serum Tox screen for asa and apap
    • CT head
  107. Weakness, Elder Abuse (neglect)
    92 y/o male found in by neighbor covered in urine and feces
    • Reporting case as mandated by law for elder abuse
    • Social work involvement
    • IV hydration
    • Check CPK for rhabdomyolysis
    • EKG
    • Work-up for infection/sepsis including UA and CXR
  108. Foot pain, Gout
    43 y/o male w/right foot pain and swelling x 4 hours
    • Joint (1st MTP) aspiration to r/o septic arthritis
    • Pain management (Indocin or colchicine)
    • Counseling on alcohol
  109. Neck Pain, Carotid Artery Dissection
    37y/o female w/headache, neck pain and visual changes
    • Pain control
    • CT head w/o contrast
    • CT neck angiography or MRA
    • Neurology consult
    • Heparin
  110. Abdominal Pain, Sigmoid Volvulus
    78y/o male from NH w/chronic constipation and abd pain
    • Pain control
    • iv line placement
    • obstructive series (AAS)
    • nasogastric tube
    • consult gastroenterology for sigmoidoscopy if no sx necrosis
    • consult general surgery for OR if sx necrosis

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