Most of the CCS cases will be demonstrated with individual one on one practice in our monthly interactive CCS Workshops. Slots are limited and you may register at http://shop.ccsworkshop.com
The cases below are followed by a very brief outline of the management are essential for obtaining high score on these CCS. Detailed practice of several cases will be performed and demonstrated in our Live CCS Webinars and in the CCS – Pay-Per-View Recorded Videos.
1. Hodgkins lymphoma : A 45 YEAR old man from presenting with lymphadenopathy. TB work up comes negative. CXR and CT scan reveals mediastinal lymphadenopathy – biopsy supraclavicular node reveals Hodgkins disease – Proceed with the case – get HIV test, staging w/u involves CT CHEST/ ABDOMEN AND PELVIS, CT reveals Lymphnodes only in mediastinal and cervical area – proceed with getting a baseline Echo and PFTs since you need to start ABVD ( Adriamycin, bleomycin, vinblastine and dacarbazine) regimen , start abvd only after echo and pft comes back as you need them before starting adria and bleo respectively – call oncology consult, call radiation oncology consult for opinion.
2. GERD/ Hiatal Hernia : 40 YEAR OLD man with hx of hiatal hernia and long lasting GERD symptoms – Start PPI trial – comes back not responsive to PPI – now, do hiatal hernia surgery/ nissen fundoplication – patient improves.
3. New HIV/ With pharyntitis vs. Thrush/ lymphadenopathy : 40 year old African American woman with dry cough and white spots. Has night sweats and weightloss, has peripheral lymphadenopathy – supraclavicular and cervical. à Rapid strep test, rx for strep pharyngitis with amoxi+clav if rapid strep +ve, if rapid strep –ve get throat cultures and empirical antibiotic, HIV test, if physical exam looks like thrush in oral cavity – start diflucan on day 1. Do additional routine w/u – CBC, CMP, U/A, UDS, CXR, LDH HIV test comes +ve, order viral load, cd4 panel, genotype. CD4 comes 50 – start MAC, PCP prophylaxis. Start HAART therapy and ID consult. CXR shows mediastinal widening – get CT scan and biopsy supraclavicular node – reveals non-hodgkin lymphoma – oncology consult, ct abdomen, ldh – case ends.
4. Acute diverticulitis
5. Femoral neck # in a 90 year old lady –90 y/o lasy after a fall and right hip pain – x-ray pelvis, hip – reveals right fem neck # – immobilization, do not forget DVT Prophylaxis, Orthopedic consult – says proceed with medical management in view of age . Continue DVT prophylaxis and physical therapy.
6. Bladder cancer: 40 year old man with history of smoking x 20 years, has not seen a doctor for 2 to 3 years comes for a general health wellness exam. All labs with urine analysis done. Showed 5 rbc/hpf with no casts. Urology consult. Since the patient has risk factor of smoking, both CT urogram + cystoscopy performed as a w/u for microscopic hematuria. Urine cytology sent for. Bladder wall biopsy +ve for transitional cell CA à PROCEED WITH STAGING W/U
7. Ascites : 50 year old man with hx of known cirrhosis presenting with enlarging abdomen and caput medusae on physical examination. All routine labs – CBC, BMP, LFT, U/A, PT, PTT, CXR, U/A ABDOMEN, hep – c serology, hep b panel, ana à Then, diagnostic paracentesis à send for protein, albumin, cytology, cell count – follow. Rx if evidence of SBP. If no evidence of SBP, proceed with ascites management with sodium restricted diet, diuretics : furosemide and spironolactone. EGD to rule out varices. If varices, start bleeding prophylaxis with propranolol ( non selective beta blocker). If hepatitis C with cirrhosis, get a alpha-fetoprotein level.
8. Asthma exacerbation : 30 y/o woman with hx of childhood asthma presents with wheezing to the ER. Routine w/u normal. CXR negative. Given albuterol + ipratropium + steroids à PEFR performed after nebulization , improved and clinically, also improved. Discharged in 1 day after improved and given oral steroids + albuterol MDI à appointment in 4 weeks à CASE ENDS ( If case proceeded, check for how many times she has used rescue inhaler in the last 2 weeks and classify her Asthma in to mild, moderate or severe so as to treat her Asthma appropriately).
9. Juvenile diabetes/ DKA : 8 year old male child with DKA
10. Adolescent Obesity – HTN 146/84 à check for TSH, CUSHING FEATURES, CMP, U/A, CBC, lipid panel, check for clues of obstructive sleep apnea à check for causes of secondary HTN ( plasma metanephrines, dexameth suppression test) – then, Sodium restricted diet, weight loss program, Exercise programà SEND HOME WITH APPOINTMENT IN 4 WEEKS TO RE-ASSESS PROGRESS.
11. Acute Lymphangitis : a 10 year old buy with low grade fever and abscess draining on his right forearm and a streak of redness radiating along the arm upwards ( a clue for acute lumphangitis) – admit, I and D if abcess, iv antibiotics, cultures.