1. health and fitness
2. disease

S E C T I O N
II
CCS Cases by Chief Complaint
C H A P T E R
5
Abdominal Pain
Key Orders*
Time to Results—ED
Setting (Stat)
Order
CCS Terminology
Pulse oximetry
Blood pressure monitor,
continuous
Cardiac monitor
Urine pregnancy test
Chest X-ray, portable
ECG, 12-lead
ABG
FAST ultrasound
Pulse oximetry
Monitor, continuous blood
pressure cuff
Monitor, cardiac
hCG, beta, urine, qualitative
X-ray, chest, AP, portable
Electrocardiography, 12-lead
Arterial blood gases
US, focused assessment
sonography for trauma
X-ray, abdomen, acute series
X-ray, chest, PA/lateral
Paracentesis, diagnostic
Paracentesis, therapeutic
X-ray, abdomen, AP
US, abdomen
CT, abdomen/pelvis, with
contrast
CT, abdomen/pelvis, without
contrast
Echocardiography
CBC with differential
Basic metabolic profile
PT/PTT
US, pelvis, transvaginal
Troponin I, serum
hCG, beta, serum, qualitative
1 min
5 min
Amylase, serum
MRI, abdomen/pelvis, with
gadolinium
MRI, abdomen/pelvis, without
gadolinium
Aortography, abdominal
Barium enema
Laparotomy
Lipase, serum
Laparoscopy
hCG, beta, serum, quantitative
1 hr
1.5 hr
MRA, abdomen
4 hr
Abdominal X-ray, acute series
Chest X-ray, PA/lateral
Abdominal tap, diagnostic
Abdominal tap, therapeutic
Abdominal flat plate X-ray
Abdominal ultrasound
Abdominal CT scan with
contrast
Abdominal CT scan without
contrast
Echocardiography
CBC with differential
BMP
PT/PTT
Transvaginal ultrasound
Troponin I, serum
Pregnancy test, serum,
qualitative
Amylase, serum
Abdominal MRI with gadolinium
Abdominal MRI without
gadolinium
Abdominal aortography
Enema, barium
Laparotomy
Lipase, serum
Laparoscopy
Pregnancy test, serum,
quantitative
Abdominal aorta MRA
5 min
5 min
10 min
15 min
18 min
20 min
20 min
20 min
20 min
20 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
30 min
45 min
1 hr
1.5 hr
2 hr
2 hr
2 hr
2 hr
2 hr 15 min
3 hr
*All orders in both columns can be recognized by the USMLE CCS Primum® software.
29
5—ABDOMINAL PAIN
Case #7
Location: Emergency Department
Chief Complaint: Abdominal pain in the right upper quadrant
Case introduction
Initial vital signs
Initial history
• A 66-year-old African-American woman is brought to the emergency department by her daughter for worsening abdominal pain over the past 2 days.
• Temperature: 40.1 degrees C (104.2 degrees F)
• Respiratory rate: 28/min
• The patient has been experiencing worsening right upper quadrant abdominal
pain over the past 2 days. The pain is a dull ache that does not radiate. The
pain has been worsening and is now rated a 6 on a 10-point scale. There
is no history of dark stools, vomiting, or diarrhea. She notes occasional
episodes of shaking chills and increasing fatigue. She has had one to two
episodes of shortness of breath on exertion in the past few days. There is no
history of cough or chest pain.
• Past medical history includes diabetes mellitus treated with metformin.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Pulse oximetry
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
90% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; appears in mild discomfort.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Dullness to percussion and crackles at right lower base.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
What is the suspected diagnosis, and what are the next steps in management?
30
II—CCS CASES BY CHIEF COMPLAINT
Case #7: Pneumonia
Keys to Diagnosis
■
■
■
Although typical symptoms include cough, dyspnea, or hemoptysis, on the CCS, look for
an atypical presentation, such as abdominal pain in an elderly or diabetic patient. Additional
symptoms include fatigue and exercise intolerance. Vital signs may show fever, tachypnea,
and tachycardia.
On chest exam, look for rales, rhonchi, decreased breath sounds, or dullness to percussion on
the affected side.
Chest X-ray, PA/lateral is the standard for diagnosing pneumonia. On the CCS, an abdominal
X-ray acute series includes a PA chest X-ray that will also detect lower lobe pneumonia. Sputum
studies can be performed if the patient has a productive cough. Lab tests (CBC, BMP, blood
cultures) are generally not needed for diagnosis unless the patient meets criteria for admission.
Management
■
Antibiotic therapy is the mainstay of treatment. Several options exist, but in general:
For a generally healthy outpatient, use an oral macrolide (azithromycin).
■ For outpatients with a comorbid condition (CHF, diabetes, alcoholism, malignancy) or
have been on an antibiotic within 90 days, use an oral fluoroquinolone (ciprofloxacin).
■ For a patient admitted to the hospital, use an IV fluoroquinolone (levofloxacin).
Decide whether to admit the patient.
■ If the vital signs are normal, pulse oximetry is normal, and chest X-ray shows localized
involvement, then outpatient therapy is adequate.
■ If the patient has comorbid conditions and abnormal vital signs such as hypotension or
tachypnea requiring oxygen, IV fluids, or IV antibiotics, then admit to inpatient unit.
■ If the patient is septic with severe hypotension, admit to ICU.
■
■
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
• Exam: lungs, abdomen
• Exam: complete
• Chest X-ray, PA/lateral (or Abdominal
• CBC, BMP, Blood culture, if
X-ray, acute series)
admitted to hospital
• Antibiotic:
• Acetaminophen, oral
• Azithromycin, oral (if outpatient and
• Reassure patient
healthy)
• Advise patient, no smoking
• Ciprofloxacin, oral (if outpatient but
comorbid conditions)
• Levofloxacin, IV (if admitted to hospital)
• Oxygen (if pulse oximetry reduced)
• Pulse oximetry
• Admit to inpatient unit if decreased pulse oximetry or if patient requires
oxygen, IV fluids, or IV antibiotics.
• Diagnosis and management should be instituted within 2 hours of simulated
time.
Orders
Exam
Orders
Clock
Orders
Location
Clock
Exam
Clock
End Orders
Pulse oximetry
General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen,
Rectal, Extremities, Neuro
Oxygen, Chest X-ray, PA/lateral (or Abdominal X-ray acute series)
Advance to X-ray results.
Antibiotic (Levofloxacin or see above), Acetaminophen, Reassure,
Advise patient no smoking CBC, BMP, Blood culture
Change to inpatient unit (if meets criteria).
Advance clock to additional updates and next day.
Interval Hx, Chest
Advance clock to case end
None
31
5—ABDOMINAL PAIN
Case #8
Location: Emergency Department
Chief Complaint: Abdominal pain in the right lower quadrant
Case introduction
Initial vital signs
Initial history
• A 26-year-old white woman is brought to the emergency department by ambulance for severe right lower quadrant abdominal pain that began 3 hours ago.
• Temperature: 38.5 degrees C (101.3 degrees F)
• Pulse: 128 beats/min
• The abdominal pain began earlier in the day as a generalized abdominal pain
then progressed over the past 3 hours to a sharp, severe pain in the right
lower quadrant. Nothing relieves the pain, which is rated 9 on a 10-point
scale. She is nauseous and vomited twice before arriving at the emergency
department. She is sexually active with two men using condoms for contraception. Her last menstrual period was 2 weeks ago.
• Past medical history includes treatment for gonorrhea 2 years ago.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
• General, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
98% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; moaning and holding her abdomen in
distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds reduced; no bruits. No masses. Right lower quadrant guarding
and rebound tenderness. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. No adnexal
masses or tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
32
II—CCS CASES BY CHIEF COMPLAINT
Case #8: Acute Appendicitis
Keys to Diagnosis
■
■
■
Abdominal pain may begin as central or epigastric before localizing to right lower quadrant.
Nausea, vomiting, and loss of appetite are also common symptoms. Vital signs may show
fever or tachycardia.
Examination shows abdominal rebound tenderness, guarding, and possibly decreased bowel
sounds. Genitalia exam is normal.
CT abdomen/pelvis without contrast is the most sensitive/specific study. Ultrasound is
preferred in pregnant women and in girls. CBC may show leukocytosis. Typical cases may
not need imaging studies, but imaging confirmation is routinely performed.
Management
■
■
■
Appendectomy (by laparoscopy or laparotomy)-generates automatic surgical consult.
IV antibiotic prophylaxis (Ampicillin sodium/-sulbactam sodium) or piperacillin-tazobactam.
Supportive care: NPO, IV fluids, correct electrolytes if needed, morphine for pain control,
Promethazine hydrochloride for nausea.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
• Exam: abdomen, genitalia
• Abdominal ultrasound (or Abdominal
CT if not young woman)
• hCG, beta, urine, qualitative (if
female)
• Normal saline 0.9% NaCl
• Appendectomy (by laparoscopy or
laparotomy)
• Ampicillin sodium/sulbactam
sodium, IV, one-time
• Exam: general, heart, lungs,
rectal
• CBC
• BMP
• Urinalysis
• Intravenous access
• Morphine, IV one-time
• Promethazine hydrochloride,
IV, one-time
• Nothing by mouth
• Reassure patient
• Cardiac monitor, blood pressure monitor, pulse oximetry (if abnormal vital
signs)
• Case is managed in the emergency department and typically ends with
the patient taken to the operating room.
• Diagnosis and management should be instituted within 1 hour of
simulated time.
Orders
Exam
Orders
Clock
Orders
Clock
End Orders
Cardiac monitor, Pulse oximetry, Blood pressure monitor
General, Chest, Heart, Abdomen, Genitalia, Rectal
hCG, Abdominal ultrasound (or CT), Morphine, Promethazine
hydrochloride (if nausea or vomiting)
Advance to ultrasound.
Appendectomy (by laparoscopy or laparotomy), CBC, BMP,
Urinalysis, Nothing by mouth, Ampicillin–sulbactam,
Reassure patient, Normal saline 0.9% NaCl
Advance to appendectomy and case end.
None
33
5—ABDOMINAL PAIN
Case #9
Location: Emergency Department
Chief Complaint: Abdominal pain radiating to back
Case introduction
Initial vital signs
Initial history
• A 52-year-old Latino man is brought to the emergency department by his
wife for worsening abdominal pain over the past 24 hours, which now is
radiating to the back.
• Temperature: 39.0 degrees C (102.2 degrees F)
• Pulse: 130 beats/min
• Respiratory rate: 27/min
• Blood pressure, systolic: 90 mm Hg
• Blood pressure, diastolic: 55 mm Hg
• The abdominal pain began yesterday with mild nausea. Overnight and
throughout today, the pain and nausea worsened with three episodes
of vomiting. The last vomiting episode had bilious vomit. The abdominal
pain is located in the left upper quadrant and is now severe, rated 9 on a
10-point scale. The pain radiates to the back, and leaning forward mildly
improves the pain.
• Past history of cholecystitis related to gallstones.
• He drinks six beers a day for the past 15 years. Smokes 5 to 10 cigarettes
a day; no history of illicit drug use.
• Family history and review of systems otherwise unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
• General, Skin, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Pulse Oximetry
Oxygen Saturation
98% (nl = 94–100)
Physical Exam Results (Pertinent Findings)
General
Well developed; holding his abdomen in distress.
Skin
Decreased turgor. No nodules or other lesions. Hair and nails normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. Basilar rales bilaterally.
Abdomen
Bowel sounds reduced; no bruits. Mild abdominal distension. Tenderness
and guarding in the epigastric and left upper quadrant region. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
Case #9: Acute Pancreatitis
Keys to Diagnosis
■
■
■
Look for a patient with severe abdominal pain, epigastric or left upper quadrant, which often
radiates to the back. Additional symptoms include nausea, vomiting, anorexia, and diarrhea.
Look for a history of gallstones or alcohol use. Vital signs show fever and tachycardia.
On exam, abdominal distention with tenderness and guarding in the upper quadrant is often
seen. Bowel sounds are typically reduced because of ileus. No occult blood on rectal exam.
Abdominal CT scan is the radiologic test of choice in severe acute pancreatitis for assessing
complications and providing prognostic information. Abdominal ultrasound and X-ray are
less useful in this setting. Lab tests such as amylase, lipase, LFT, and others listed below
provide additional support and help determine prognostic information.
Management
■
■
■
■
Provide aggressive supportive care: Oxygen, NPO, IV fluids, Monitor urine output, Nausea
control (Promethazine) and pain relief-Hydromorphone hydrochloride (Dilaudid).
Antibiotic use is controversial. Currently not recommended for prophylaxis; recommended
only if acute necrotizing pancreatitis is present.
Endoscopic retrograde cholangiopancreatography (ERCP) if imaging and laboratory studies
consistent with severe acute gallstone pancreatitis.
Surgical consult in gallstone pancreatitis to evaluate if the patient should have cholecystectomy.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
• Exam: General, Chest, Heart,
Abdomen
• CT, abdomen/pelvis without
contrast
• Amylase, serum
• Lipase, serum
• BMP
• CBC
• LFT
THERAPY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
MONITORING
LOCATION
•
•
•
•
TIMING
•
SEQUENCING
Orders
Exam
Orders
ABG
Troponin I
ECG, 12-lead
PT/PTT
Triglycerides, blood
Phosphorus, serum
Magnesium, serum
Urinalysis
Blood culture
hCG, beta, urine, qualitative, stat (if female)
Normal saline solution, 0.9% NaCl
Nasogastric tube
Oxygen
Consult, general surgery (or ERCP)Nothing by mouth
if gallstones on imaging
Hydromorphone Hydrochloride
• Promethazine hydrocholoride (Phener(Dilaudid), IV
gan), IV for nausea
• Vital signs
Blood pressure monitor
• Foley catheter
Pulse oximetry
Cardiac monitor
• Urine output
Transfer to ICU for initial monitoring then to inpatient unit once patient has stable
vital signs. Patient may be taken to surgery with surgical consult.
Initial diagnosis and management including pain relief and IV fluids should be
instituted within 1 hour of simulated time.
Clock
Orders
Location
Clock
Exam
Clock
End Orders
Blood pressure monitor, Cardiac monitor, Pulse oximetry
General, Skin, Chest, Heart, Abdomen, Rectal
Abdominal CT scan, BMP, Amylase, Lipase, CBC, Troponin, ECG,
ABG, LFT, PT/PTT, Triglycerides, Oxygen, IV access, Normal
saline, Hydromorphone, Promethazine
Advance to results of CT scan.
Consult, general surgery (if gallstones), Foley catheter, Urine output
Change to ICU
Advance to additional results and patient updates.
General, Abdomen +/- Others
Advance to additional updates and case end.
Consider counseling orders
35
5—ABDOMINAL PAIN
Case #10
Location: Emergency Department
Chief Complaint: Abdominal pain and chest pain
Case introduction
Initial vital signs
Initial history
• A 9-year-old African-American boy is brought to the emergency department
by his mother for severe abdominal and chest pain over the past 2 hours.
• Temperature: 38.3 degrees C (101.0 degrees F)
• Other vital signs unremarkable
• The pain has been worsening over the past 2 hours and is located in the
chest, abdomen, and arms. Nothing relieves the pain, which is rated 9 on
a 10-point scale. The patient had an upper respiratory tract infection that
began 3 days ago. There is no history of constipation or diarrhea.
• Past medical history of sickle cell anemia diagnosed at age 1. All vaccinations, including pneumococcal and Hemophilus, are up to date. Medications
include prophylactic penicillin.
• Family history, developmental history, and review of systems are otherwise
unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in distress, holding his chest and abdomen.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Basilar rales present.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
Neuro/Psych
Alert; neurologic findings normal.
What is the suspected diagnosis, and what are the next steps in management?
36
II—CCS CASES BY CHIEF COMPLAINT
Case #10: Sickle Cell Anemia with Vaso-Occlusive Crisis
Keys to Diagnosis
■
■
■
The diagnosis is based on history of pain in a patient with known sickle cell anemia. Crisis
is often precipitated by dehydration, infection, pregnancy, stress, or cold weather. Vital signs
will show fever with acute chest syndrome.
Examination is generally unremarkable.
Order chest X-ray looking for acute chest syndrome (pulmonary infiltrates on CXR, chest
pain, and fever). Order sputum studies if productive cough. If CBC shows severe anemia,
order reticulocyte count looking for aplastic crisis (low reticulocyte count). In older patients,
consider abdominal ultrasound to evaluate for gallstones.
Management
■
■
■
■
■
■
Treatment is mainly supportive: hydration with IV fluids, pain control with morphine and
NSAIDs, oxygen if hypoxia, incentive spirometry.
Hydroxyurea is used in the chronic setting after initial management to prevent future attacks.
Transfusion if significant anemia or thrombocytopenia present (aplastic crisis).
Empiric antibiotics in acute chest syndrome (Azithromycin).
Hematology consult optional.
If gallstone cholecystitis present, consider surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
•
•
•
•
•
THERAPY
•
•
•
•
MONITORING •
LOCATION
•
TIMING
•
ADDITIONAL ORDERS
Chest X-ray, PA/lateral
CBC
Reticulocyte count
Blood culture
Urine culture
• Exam: Additional
• Abdominal ultrasound
• ECG
• Troponin
• BMP
• Urinalysis
• Amylase, Lipase
• hCG, beta, urine, qualitative (if female)
Oxygen
• Hydroxyurea, oral
Normal saline 0.9% NaCl
• Ibuprofen
Morphine, IV
• Incentive spirometry
Antibiotics (if acute chest
• Transfusion RBC (only if severe anemia)
syndrome—Azithromycin, IV)
• Reassure patient
Pulse oximetry
• CBC
• Urine output
Initial management in the emergency department with change to inpatient unit for
monitoring.
Diagnosis and management should be instituted within 2 hours of simulated time.
SEQUENCING Orders
Exam
Orders
Clock
Orders
Clock
Location
Exam
Orders
Clock
End Orders
Pulse oximetry
General, Skin, Lungs, Heart, Abdomen, Rectal ± Others
Chest X-ray PA/lateral, Oxygen, Intravenous access, Normal saline
0.9% NaCl, Morphine
Advance to chest X-ray results.
CBC, Reticulocyte count, Abdominal ultrasound (if possible cholecystitis),
ECG, BMP, Troponin, Amylase, Lipase, LFT, Blood culture, Urinalysis,
Urine culture, Type and crossmatch blood, Antibiotics (Azithromycin)
Advance to additional results and patient update.
Change to inpatient unit.
General, Chest +/- Others
Incentive spirometry, Reassure, Counsel family
Advance to additional patient updates and case end.
Hydroxyurea, any follow-up labs needed.
37
5—ABDOMINAL PAIN
Case #11
Location: Emergency Department
Chief Complaint: Abdominal pain and vaginal spotting
Case introduction
Initial vital signs
Initial history
• A 22-year-old white woman is brought to the emergency department by her
roommate for worsening abdominal pain over the past 6 hours.
• Temperature: 38.0 degrees C (100.5 degrees F)
• Pulse: 105 beats/min
• Blood pressure, systolic: 90 mm Hg
• Blood pressure, diastolic: 62 mm Hg
• The patient has had worsening abdominal pain over the past 6 hours that is
now a constant, sharp, and focused pain in the right lower quadrant. Nothing
relieves the pain, which is rated 10 on a 10-point scale. She has had occasional episodes of vaginal spotting over the past 2 days. There is no history of
constipation or diarrhea. She is sexually active with three men with occasional
use of condoms for contraception. Her last menstrual period was 6 weeks
ago.
• Past medical history includes treatment for chlamydia infection 6 months ago.
She is on no current medications.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
• General, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in acute distress, moaning and holding her
abdomen.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms
Abdomen
Bowel sounds normal; no bruits. Right lower quadrant tenderness on
palpation. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal lesions. Cervical os closed with cervical motion
tenderness present. Uterus mildly enlarged. Right adnexal mass with
tenderness.
What is the suspected diagnosis, and what are the next steps in management?
38
II—CCS CASES BY CHIEF COMPLAINT
Case #11: Ectopic Pregnancy
Keys to Diagnosis
■
■
■
Look for the classic triad of abdominal/pelvic pain, amenorrhea, and vaginal bleeding.
Additional symptoms may include nausea, breast fullness, fatigue, heavy cramping, shoulder
pain, and dyspareunia. Vital signs may be normal or show hypotension and tachycardia.
On examination, look for abdominal tenderness, adnexal mass and tenderness, enlarged
uterus, and cervical motion tenderness.
The most important diagnostic studies are hCG urine to confirm pregnancy and transvaginal
ultrasound to rule out intrauterine pregnancy.
Management
■
Treatment depends on whether the patient is stable or unstable.
If unstable, as in this case, proceed to laparotomy or laparoscopy. Order pain relief
(morphine).
■ If stable, consider laparoscopy or medical management with methotrexate. Consider
methotrexate if the patient is compliant; adnexal mass <3.5cm; quantitative hCG <15,000;
and there is no history of renal disease, liver disease, or cytopenia. (Order quantitative
hCG, CBC, BMP, and LFT before administering medication and advise against alcohol,
NSAIDs, and sex.)
Monitor quantitative hCG weekly until results are negative.
■
■
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
• Exam: genitalia, abdomen
• hCG, beta, urine, qualitative
• Transvaginal ultrasound
THERAPY
•
•
•
MONITORING
•
•
•
•
•
•
•
•
•
•
•
LOCATION
•
•
Exam: lungs, heart
CBC
BMP
PT/PTT
hCG, beta, serum, quantitative
Laparotomy
Consult, obstetrics and gynecology
Type and crossmatch, blood
Morphine, IV, one-time/bolus
RhoGAM, IM
Normal saline, 0.9% NaCl (if
Advise patient, safe sex techniques
hypotension)
Monitor quantitative hCG weekly until
Blood pressure monitor,
continuous (if hypotension)
negative
Initial management in emergency department with patient taken to surgery
if unstable.
If stable and management with methotrexate desired, can be treated as an
outpatient.
Diagnosis and management should be instituted within 2 hours of simulated
time.
TIMING
•
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor (if hypotension)
Abdomen, Genitalia, General, Heart, Lungs
hCG urine, Morphine
Advance to hCG result.
Transvaginal ultrasound, Intravenous access, Normal saline, CBC,
BMP, PT/PTT
Advance to ultrasound result.
Laparotomy (or laparoscopy or Consult Ob-Gyn), Type and
crossmatch blood
Advance to consult and case end.
hCG serum quantitative, RhoGAM; Advise patient safe sex
techniques
39
5—ABDOMINAL PAIN
Case #12
Location: Office
Chief Complaint: Epigastric pain and fatigue
Case introduction
Initial vital signs
Initial history
• A 62-year-old African-American man presents to the office with a 3-month history of epigastric pain.
• Height: 168 cm (66.0 in)
• Weight: 97.5 kg (215.0 lb)
• Body mass index: 34.7 kg/m2
• The patient describes intermittent epigastric pain over the past 3 months generally occurring after meals. He has had some epigastric discomfort for more
than 2 years. The pain is usually relieved with over-the-counter antacids. The
pain is associated with nausea, occasional episodes of vomiting, and belching.
The pain appears to worsen at night when lying down. He has also noticed
increasing fatigue and tiredness over the past 3 months. There is no history of
fever, constipation, or diarrhea.
• Past medical history is unremarkable.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals,
and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. No masses or tenderness. Liver and spleen
not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
40
II—CCS CASES BY CHIEF COMPLAINT
Case #12: Gastroesophageal Reflux Disease/Barrett
Esophagus
Keys to Diagnosis
■
■
■
Symptoms include heartburn, regurgitation, dysphagia, and reflux. Less commonly, may see
chronic cough, chest pain, and bronchospasms. Vital signs may show the patient is overweight.
Examination is generally unremarkable and should not show occult blood on rectal exam.
The diagnosis is usually made on history. Endoscopy is generally recommended one
time in patients age older than 50 years with a history of chronic GERD to evaluate for
complications, such as ulcers, Barrett esophagus, and cancer.
Management
■
■
■
■
■
■
Treatment for GERD and Barrett esophagus without dysplasia is similar.
Proton pump inhibitors are first line (e.g., omeprazole).
Lifestyle modifications are imperative—avoid smoking and alcohol, advise sitting up after
meals, diet and exercise for weight loss.
Patients with Barrett esophagus should undergo surveillance endoscopy every 2 years or less.
Testing and treating for Helicobacter pylori in GERD has not been shown to improve
symptoms.
If biopsy shows high-grade dysplasia, refer for surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
• Endoscopy, upper
• ECG, 12-lead (if chest pain present)
gastrointestinal
• Esophageal biopsy
• Omeprazole, oral, continuous
• Diet calorie restricted (if BMI elevated)
• Advise no smoking
• Advise exercise program
• Advise limit alcohol intake
• Reassure patient
• Advise sit upright after meals
• Advise side effects of medication
• Patients with Barrett esophagus should undergo surveillance endoscopy every
2 years or less.
• Office with outpatient management.
• Diagnosis and management should be instituted within 4 days of simulated
time.
Exam
Orders
Clock
Orders
Clock
End Orders
General, Heart, Lung, Abdomen, Rectal ± Others
Endoscopy upper gastrointestinal, Esophageal biopsy
Advance clock (reschedule patient) after results of endoscopy
and biopsy.
Omeprazole, Diet calorie restricted, Advise side effects of
medication, Advise exercise program, Advise no smoking,
Advise limit alcohol, Advise sit upright after meals, Counsel
patient, Reassure patient
Advance clock to see patient as needed for patient updates and
case end.
None
41
5—ABDOMINAL PAIN
Case #13
Location: Emergency Department
Chief Complaint: Abdominal pain and vomiting in an infant
Case introduction
Initial vital signs
Initial history
• An 18-month-old Native American boy is brought to the emergency department by his mother for abdominal pain and vomiting over the past 3 hours.
• Unremarkable
• The mother describes progressively worsening abdominal pain over the past
3 hours with increased fussiness and crying. The pain occurs for 10 to 15
minutes at a time and then is relieved for 30 to 40 minutes. During painful
episodes, the patient lies down and pulls his legs toward his abdomen. The
patient had three episodes of vomiting before arrival with food and bile in the
vomit but no blood. The mother also noted dark, loose stools. There has been
no change in diet and no recent travel history. There is no fever, constipation,
diarrhea, or recent history of infection.
• Past medical history is unremarkable.
• Family history, developmental history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal,
Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed infant, crying and fussy.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination,
normal. Hearing normal. Ears, including pinnae, external auditory canals, and
tympanic membranes, normal. Nose and mouth normal. Pharynx normal.
Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds reduced. Tenderness and fullness present in the right upper
quadrant. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses. Currant jelly stool; Occult blood positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
42
II—CCS CASES BY CHIEF COMPLAINT
Case #13: Intussusception
Keys to Diagnosis
■
■
■
Look for a child younger than 2 years old with the classic triad of abdominal pain, vomiting,
and bloody stools. The pain typically is cyclical, lasting 10 to 15 minutes, and the patient
often draws their legs up to the abdomen. Additional symptoms include lethargy; diarrhea,
which may be bloody; and recent viral infection.
Examination may show a “sausage-like” abdominal mass in one quadrant (usually right upper quadrant). Also, look for bloody or “Currant jelly” stools.
Initial screening with ultrasound or abdominal X-rays. Ultrasound is more commonly used
and will more clearly identify the intussusception. X-rays may show a soft tissue mass and
dilated loops of bowel (obstruction). If ultrasound or X-ray results are normal, intussusception is unlikely. CBC and BMP for screening.
Management
■
■
■
Barium enema is both diagnostic and therapeutic. Note: air enema is not an option on the
CCS. 24-hour observation in hospital after reduction is recommended.
IV access, normal saline, NPO, and pain relief.
If barium enema fails or if perforation is present, surgical consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
• Exam: abdomen, rectal
• Abdominal ultrasound (or X-ray)
• Barium enema
• CBC
• BMP
• Intravenous access
• Normal saline
• NPO
• Morphine (or Ibuprofen)
• Monitor in hospital for 24 hours after reduction.
• Management in ED with hospital admission for monitoring
• Diagnosis and management should be instituted within 2 hours of simulated
time.
Exam
Orders
Clock
Orders
Clock
Location
Clock
Exam
Clock
End Orders
Abdomen, Rectal, Heart, Lungs ± Others
Abdominal ultrasound
Advance to ultrasound.
Barium enema, Intravenous access, Normal saline, NPO,
Morphine, CBC, BMP
Advance to barium enema.
Change to inpatient unit.
Advance to patient updates.
General, Abdomen
Advance to case end.
Counsel family, Reassure
5—ABDOMINAL PAIN
43
Case #14
Location: Emergency Department
Chief Complaint: Abdominal pain and constipation
Case
introduction
Initial vital signs
Initial history
• A 74-year-old white woman is brought to the emergency department from her
nursing home for worsening abdominal pain and constipation over the past 3 days.
• Unremarkable
• The patient is brought to the emergency department by ambulance with her nurse,
who describes increasing abdominal discomfort over the past 3 days. The patient
lives in a nursing home and is bedridden. She has a history of stroke and has
aphasia. Her nurse also reports lack of bowel movement for the past 3 days. She
has vomited twice with bilious vomit before arrival. There is no history of fever.
• Past medical history includes hypertension, multiple strokes, and arthritis.
• Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Patient appears uncomfortable and fidgeting in bed.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds high pitched and hyperactive. Abdominal fullness and tenderness.
Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Neuro/Psych
Patient aphasic and bedridden. Deep tendon reflexes normal.
What is the suspected diagnosis, and what are the next steps in management?
44
II—CCS CASES BY CHIEF COMPLAINT
Case #14: Sigmoid Volvulus
Keys to Diagnosis
■
■
■
Look for an adult older than 60 years with the classic triad of abdominal pain, abdominal
distention, and constipation.
Examination shows abdominal distention and tenderness with either hyperactive or
decreased bowel sounds.
Abdominal X-ray is diagnostic in most cases.
Management
■
■
■
A volvulus should be reduced. Options for reduction include sigmoidoscopy, anoscopy, rectal
tube, and barium enema.
CBC, PT/PTT, and BMP are optional routine evaluations in this setting.
Surgical consult should be made for consideration of surgical resection because volvulus
often recurs.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
• Exam: abdominal
• Abdominal x-ray,
acute series
THERAPY
•
•
•
•
•
•
•
•
•
• Sigmoidoscopy,
flexible (or rectal
tube)
• Consult, general
surgery
• Vital signs as needed
• Emergency department transfer to inpatient unit for observation.
• Diagnosis and management should be instituted within 2 hours of simulated
time.
Exam
General, Heart, Lungs, Abdomen, Rectal ± Others
Orders
Abdominal X-ray, acute series
Clock
Advance to abdominal X-ray.
Orders
Sigmoidoscopy, flexible, Morphine, Promethazine
Clock
Advance to sigmoidoscopy results.
Exam
Abdomen +/- Others
Orders
Consult surgery, Reassure
Location
Change to inpatient unit
Clock
Advance to surgery consult, additional updates and case end.
End Orders
None
MONITORING
LOCATION
TIMING
SEQUENCING
Exam: skin, lungs, heart, rectal
CBC
BMP
PT/PTT
Intravenous access
Normal saline, 0.9% NaCl
Morphine for pain
Promethazine hydrochloride for nausea
Reassure patient
45
5—ABDOMINAL PAIN
Case #15
Location: Emergency Department
Chief Complaint: Abdominal pain with a past history of trauma
Case introduction
Initial vital signs
Initial history
• A 37-year-old white man is brought to the emergency department by his wife
for worsening abdominal pain over the past 2 hours.
• Respiratory rate: 22/min
• The patient describes worsening abdominal pain over the past 2 hours. The
pain is generalized and crampy and occurs at intervals, with severe pain for several minutes followed by several minutes of pain relief. When severe, the pain
is rated 8 on a 10-point scale. The patient tried acetaminophen, which did not
relieve the pain. There is no history of infection, fever, constipation, or diarrhea.
• Past medical history of abdominal surgery for a gunshot wound 3 years ago.
• Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in moderate distress, holding his abdomen.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Abdominal scar from previous surgery. Hyperactive bowel sounds. Moderate
abdominal distention and tenderness. Liver and spleen not palpable. No
hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
What is the suspected diagnosis, and what are the next steps in management?
46
II—CCS CASES BY CHIEF COMPLAINT
Case #15: Small Bowel Obstruction
Keys to Diagnosis
■
■
■
Abdominal pain is typically crampy and occurs every few minutes. Nausea, vomiting, and
constipation may also be seen. Look for history of prior abdominal surgery or trauma.
Abdominal exam may show distention, tenderness, and hyperactive or diminished bowel
sounds.
Abdominal X-ray is generally diagnostic and shows dilated loops of small bowel with
multiple air-fluid levels. Abdominal CT is increasingly used because it is better at defining
the site of obstruction and possible cause.
Management
■
■
■
■
■
Surgical consult for repair.
IV access and fluid resuscitation.
Nasogastric tube with enteral decompression to remove gas and fluid proximal to the
obstruction.
Broad-spectrum antibiotic (Cefoxitin) is typically used if surgical management is planned.
Routine orders: CBC, BMP, PT/PTT, pain control, nausea control, type and crossmatch
blood.
OPTIMAL ORDERS
DIAGNOSIS
• Exam: abdomen, rectal
• Abdominal CT (or Abdominal
X-ray, acute series)
THERAPY
•
•
•
MONITORING
LOCATION
TIMING
•
•
•
SEQUENCING
Exam
Orders
Clock
Orders
ADDITIONAL ORDERS
• Exam: additional ± complete
• CBC
• BMP
• PT/PTT
• Intravenous access
Consult, general surgery
Nasogastric tube
• Morphine
Normal saline, 0.9% NaCl
• Promethazine hydrochloride
• Cefoxitin
• Type and crossmatch, blood
• Nothing by mouth
• Reassure patient
Not important in the time frame of this case
Emergency department
Diagnosis and management should be instituted within 1 hour of simulated time.
Clock
End Orders
General, Heart, Lungs, Abdomen, Rectal ± Others
Abdominal CT (or Abdominal X-ray, acute series)
Advance to imaging results.
Intravenous access, Normal saline, Consult general surgery,
Nasogastric tube, Nothing by mouth, CBC, BMP, PT/PTT,
Meperidine, Metoclopramide, Cefoxitin, Type and crossmatch
blood, Reassure patient
Advance to surgery consult and case end.
None
47
5—ABDOMINAL PAIN
Case #16
Location: Office
Chief Complaint: Abdominal pain and flank pain
Case introduction
Initial vital signs
Initial history
• A 42-year-old white man presents to the office with a 2-month history of abdominal pain, flank pain, and fatigue.
• Blood pressure, systolic: 160 mm Hg
• Blood pressure, diastolic: 100 mm Hg
• The patient has had intermittent lower abdominal and flank pain for the past 2
months. The pain is described as a dull ache. Ibuprofen sometimes relieves the
pain, which is rated 4 on a 10-point scale. He has occasional episodes of light
brown-colored urine and occasionally gets generalized headaches. There is no
history of fever, night sweats, constipation, or diarrhea.
• Past medical history of urinary tract infection treated 1 month ago.
• Family history includes a father who died of kidney failure at age 62 years.
• Social history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia,
Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure equal
in both arms.
Abdomen
Bowel sounds normal; no bruits. Bilateral masses palpable. Liver and spleen
not palpable. No hernias.
Genitalia
Normal circumcised penis; normal scrotum; testes without masses. No inguinal
hernia.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal. Bilateral flank masses present.
Neuro/Psych
Mental status normal. Findings on cranial nerve, motor, and sensory
examinations normal. Cerebellar function normal. Deep tendon reflexes
normal.
What is the suspected diagnosis, and what are the next steps in management?
48
II—CCS CASES BY CHIEF COMPLAINT
Case #16: Adult Polycystic Kidney Disease
Keys to Diagnosis
■
■
■
Common symptoms include pain (abdominal or flank), fatigue, weakness, hypertension,
headache, nocturia, and hematuria. Look for family history of renal failure. Vital signs may
show hypertension.
Exam may show abdominal or flank mass.
Abdominal ultrasound or CT confirms the diagnosis. Evaluate for anemia, electrolyte
abnormalities, renal failure, UTI and hyperlipidemia.
Management
■
■
■
■
■
Control blood pressure with an ACE inhibitor and a low-sodium diet.
Treat any renal failure, electrolyte abnormality, hematuria, or UTI (e.g., ciprofloxacin).
Consider MRA brain to evaluate for intracranial aneurysms if the patient is in a high-risk job
or there is family history of stroke.
Reduce pain (avoid NSAIDs, treat pain with surgical drainage of cyst).
Nephrology and/or surgical consult is generally recommended, along with genetics consult.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
•
•
•
•
•
•
•
•
•
•
•
ADDITIONAL ORDERS
Exam: abdomen, back
Abdominal ultrasound or CT
CBC
BMP
Urinalysis
Lisinopril
Diet low sodium
• Exam: complete
• Urine culture
• Urine cytology
• Uric acid
• Lipid profile
• Consult, nephrology
• Consult, general surgery
• Diet low protein
• Advise patient, no contact sports
• Reassure patient
Not important for the time frame of this case
Most cases can be managed as outpatients in the office.
Admit if septic or severe pain.
Diagnosis and management should be instituted within 3 days of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Abdominal, Extremities, Heart, Lungs ± Others
Abdominal ultrasound
Advance clock 30 min to abdominal ultrasound results.
CBC, BMP, Lipid profile, Urinalysis, Urine culture, Urine cytology,
Lisinopril, Diet low sodium, Diet low protein, Advise no contact
sports, Counsel, Reassure. Consider MRA brain if patient meets
criteria.
Reschedule patient after results are reported.
Consult general surgery, Consult nephrology, Consult genetics, Treat
any complications (UTI, renal failure, hyperkalemia)
Advance to additonal results, updates and case end
None
49
5—ABDOMINAL PAIN
Case #17
Location: Office
Chief Complaint: Abdominal discomfort and distention
Case introduction
Initial vital signs
Initial history
• A 47-year-old African-American woman presents to the office with a 1-month
history of increasing abdominal discomfort and distention.
• Unremarkable
• The patient reports increasing abdominal distention and discomfort over the
past month. The abdominal fullness has caused increased urinary frequency,
nocturia, reflux, and belching. She has occasional episodes of shortness of
breath. There is no change in appetite or diet. There is no history of fever,
constipation, or diarrhea.
• Past medical history of three childbirths with normal vaginal deliveries.
• Patient has smoked two packs of cigarettes a day for the past 20 years. No
history of significant alcohol or illicit drug use.
• Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Breasts, Lymph nodes, HEENT, Chest, Heart, Abdomen, Genitalia, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in no apparent distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Breasts
Nipples normal; no masses.
Lymph nodes
No abnormal lymph nodes.
HEENT/Neck
Normocephalic. Vision normal. Eyes, including funduscopic examination, normal.
Hearing normal. Ears, including pinnae, external auditory canals, and tympanic
membranes, normal. Nose and mouth normal. Pharynx normal. Neck supple;
no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. Mild dullness to percussion and reduced breath sounds at bases.
Heart/
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
Cardiovascular
peripheral pulses normal. No jugular venous distention. Blood pressure equal in
both arms.
Abdomen
Bowel sounds normal; no bruits. Abdominal fullness and tenderness with shifting
dullness. Liver and spleen not palpable. No hernias.
Genitalia
Normal labia. No vaginal or cervical lesions. Uterus not enlarged. Left adnexal
mass.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of motion.
Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
50
II—CCS CASES BY CHIEF COMPLAINT
Case #17: Ovarian Cancer
Keys to Diagnosis
■
■
■
Common symptoms include abdominal fullness, distention, and discomfort with associated
symptoms—urinary frequency, constipation, indigestion, reflux, and shortness of breath,
tiredness, and weight loss.
Exam may show pelvic or adnexal mass, ascites, or signs of pleural effusion.
Abdominal/pelvic ultrasound is the most useful initial study. Tumor markers include
CA-125, hCG, and alpha-fetoprotein. Screen with mammography and chest X-ray.
Management
■
■
■
Surgical consult or laparoscopy.
Medical Oncology consult for possible chemotherapy (for stage II or greater).
Counseling and reassurance.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•
•
•
•
•
Exam: abdomen, genitalia
Pelvic ultrasound
Paracentesis
Ascitic fluid cytology
CA-125, serum
THERAPY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Advise patient cancer diagnosis
Consult general surgery
Reassure patient
None
Office to inpatient unit for management of ascites
Diagnosis and management should be instituted within 2 days of simulated time.
MONITORING
LOCATION
TIMING
SEQUENCING
Exam
Location
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Mammogram
Chest x-ray (CXR) PA/Lateral
Pap smear
Alpha-fetoprotein, serum
HCG, beta, serum, quantitative
CBC
BMP
Consult hematology/oncology
Advise patient, no smoking
General, Heart, Lungs, Abdomen, Genitalia ± Others
Change to inpatient unit.
Chest X-ray, PA/lateral, Pelvic ultrasound
Advance clock to results.
Paracentesis, Ascitic fluid cytology, CA-125 serum, Alphafetoprotein serum, HCG beta serum quantitative, CBC, BMP
Advance clock to results of cytology.
Consult general surgery, Advise patient cancer diagnosis, Consult
hematology/oncology, Reassure patient
Advance to surgical consult and case end.
None
51
5—ABDOMINAL PAIN
Case #18
Location: Emergency Department
Chief Complaint: Abdominal pain and vaginal discharge
Case introduction
Initial vital signs
Initial history
• A 22-year-old white woman is brought to the emergency department by her
sister for increasing lower abdominal pain over the past 2 days.
• Temperature: 38.3 degrees C (101.0 degrees F)
• The patient has had fever and chills for 2 days with abdominal pain that began
as a dull ache and now is generalized and moderate in severity, rated as a 6 on
a 10-point scale. Several hours ago, she had onset of a foul-smelling vaginal
discharge with nausea and one episode of vomiting. She has had two episodes
of painful intercourse over the past week. Her last menstrual period was 3
weeks ago. She has three male sexual partners and occasionally uses condoms for contraception. She drinks alcohol on weekends and has no history of
smoking or illicit drug use.
• Past medical history of treatment for gonorrhea 4 months ago and chlamydia 2
years ago. She was treated for a urinary tract infection 8 months ago. She had
a normal Pap smear result 4 months ago.
• Family history, social history, and review of systems are otherwise unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Breasts, Lymph nodes, Chest, Heart, Abdomen, Genitalia, Rectal
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Breasts
Nipples normal; no masses.
Lymph nodes
Mildly enlarged inguinal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds normal; no bruits. Bilateral lower abdominal tenderness. Liver
and spleen not palpable. No hernias.
Genitalia
Normal labia. Mucopurulent vaginal discharge present. Cervical motion
tenderness present. Uterus not enlarged. Bilateral adnexal tenderness.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; no occult
blood.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
52
II—CCS CASES BY CHIEF COMPLAINT
Case #18: Pelvic Inflammatory Disease
Keys to Diagnosis
■
■
■
Look for a young woman with abdominal/pelvic pain, vaginal discharge, dysuria, and pain or
bleeding with intercourse. History may show multiple sexual partners, prior STI, or lack of
condom use. Vital signs show a fever.
Examination shows purulent vaginal discharge, adnexal tenderness, or cervical motion tenderness.
Order hCG to rule out pregnancy. Abdominal or transvaginal ultrasound may show fallopian
tube dilation or abnormalities in the ovaries. MRI has higher sensitivity than ultrasound
but is more costly. Order studies for sexually transmitted diseases: chlamydia, gonorrhea,
Trichomonas, HIV, hepatitis.
Management
■
■
■
Decide whether to admit: tubo-ovarian abscess, pregnant, immunodeficient, severe illness,
noncompliant.
Antibiotic treatment should be effective against gonorrhea and chlamydia + anerobes.
If inpatient, use cefotetan IV or cefoxitin IV + doxycycline oral. Stop IV meds 24 hours after
improvement, but continue Doxycycline for 14 days. If tubo-ovaian abscess present, add
Metronidazole, oral for 14 days. If outpatient treatment, use ceftriaxone IM single dose +
doxycycline oral for 14 days + metronidazole oral for 14 days.
Counseling to avoid sex, use safe sex techniques, and treat partners if needed.
OPTIMAL ORDERS
DIAGNOSIS
THERAPY
MONITORING
LOCATION
TIMING
SEQUENCING
ADDITIONAL ORDERS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
hCG, beta, urine qualitative
• CBC
Transvaginal ultrasound
• BMP
Vaginal pH
• Urinalysis
Vaginal secretion, wet mount
• Urine culture
Vaginal KOH prep
• Hepatitis B surface antigen, serum
Cervical DNA, gonorrhea
• Hepatitis C antibody, serum
Cervical DNA, chlamydia
HIV antibody test, rapid, blood
Intravenous access
• PT/PTT
Cefotetan, IV
• NSAID or morphine
Doxycycline, oral
• Advise patient, safe sex
Consult, general surgery
• Advise patient, treat partner
Monitor vital signs if needed.
Emergency department to inpatient unit if patient meets criteria and needs
parenteral antibiotic therapy or possible surgery.
• Outpatient therapy if patient stable and compliant.
• Diagnosis and management should be instituted within 4 hours of simulated time.
Exam
Orders
Clock
Orders
Clock
Orders
Location
Clock
Orders
Clock
End Orders
General, Skin, Heart, Lungs, Abdomen, Genitalia, Rectal ± Others
hCG urine, qualitative
Advance to hCG results.
Transvaginal ultrasound, Vaginal pH, Vaginal wet mount, Vaginal KOH
prep, Cervical DNA, gonorrhea, Cervical DNA, chlamydia, HIV rapid
test, Urinalysis, Urine culture
Advance to transvaginal ultrasound results.
Antibiotics (Cefotetan, Doxycycline or see above), Consult surgery,
CBC, BMP, Hepatitis B surface antigen, Hepatitis C antibody
Change to inpatient unit (if patient meets criteria).
Advance to additional results.
Advise patient: avoid sex, safe sex techniques, treat partners
Advance to patient updates and case end
None
53
5—ABDOMINAL PAIN
Case #19
Location: Emergency Department
Chief Complaint: Severe epigastric pain
Case introduction
Initial vital signs
Initial history
• A 46-year-old man is brought to the emergency department by his wife 45
minutes after onset of severe epigastric pain.
• Pulse: 126 beats/min
• Respiratory rate: 26/min
• Blood pressure, systolic: 104 mm Hg
• Blood pressure, diastolic: 62 mm Hg
• The patient experienced sudden onset of severe epigastric pain 45 minutes
ago while he was resting at home. The pain is constant and rated 10 on a
10-point scale. The pain radiates to the left shoulder. Changing body position
does not relieve the pain. In addition, he has been feeling increased fatigue over
the past 2 months. He has had heartburn over several years treated with antacids, which appears to have been worsening over the past 2 months. There is
no shortness of breath, constipation, or diarrhea.
• Past medical history includes heartburn treated with over-the-counter antacids
and a motor vehicle accident 4 years ago.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
• General, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, mildly overweight. Moaning, lying immobile, holding his stomach
in distress.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Heart/
Tachycardic. S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds.
Cardiovascular
Central and peripheral pulses weak. No jugular venous distention. Blood
pressure equal in both arms.
Abdomen
Bowel sounds absent; no bruits. Abdomen diffusely tender and rigid. No
hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult blood
positive.
What is the suspected diagnosis, and what are the next steps in management?
54
II—CCS CASES BY CHIEF COMPLAINT
Case #19: Peptic Ulcer Disease with Perforation
Keys to Diagnosis
■
■
■
For peptic ulcer disease, look for epigastric pain that is gnawing or burning, occurring after
meals, and that may be relieved by foods or antacids. Other symptoms include belching,
bloating, heartburn, melena, fatigue from anemia, and weight loss. In patients with perforation, look for more severe, sharp abdominal pain with abnormal vital signs.
On exam, peptic ulcer disease may show mild tenderness. If perforated, abdominal rebound
tenderness, guarding, and rigidity are present. Stool occult blood positive.
Endoscopy is the diagnostic test of choice in peptic ulcer disease, however should not be used
if perforation suspected. A chest X-ray may show free abdominal air in perforation. Abdominal
CT scan is typically used as the primary diagnostic modality in perforation. Baseline testing
for CBC, BMP, type and crossmatch, PT/PTT, LFT, amylase, and lipase is recommended.
Testing for H. pylori is generally performed.
Management
■
■
For nonperforated ulcers: treat H. pylori (PPI + two antibiotics; e.g., omeprazole + clarithromycin + amoxicillin); avoid NSAIDs, alcohol, and smoking.
For perforation and an unstable patient: IV access and normal saline, ABCs (intubation
if needed), nasogastric tube suction, urgent surgical consult, IV proton pump inhibitor
(e.g., Pantoprazole sodium), IV antibiotics (e.g., metronidazole + gentamicin) and eventual
treatment of H. pylori.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•
•
•
•
Abdominal X-ray, acute series
Abdominal CT
CBC
PT/PTT
THERAPY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Morphine, IV
Consult, Surgery
Type and crossmatch, blood
Pantoprazole sodium, IV
Metronidazole, IV
Gentamicin, IV
Blood pressure monitor, continuous
Pulse oximetry
Cardiac monitor
For perforation, initial management in the ED with surgical referral.
Diagnosis and management should be instituted within 2 hours of simulated
time.
MONITORING
LOCATION
TIMING
SEQUENCING
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
ECG, 12-lead
Troponin I
BMP
LFT
Amylase, serum
Lipase, serum
Intravenous access
Normal saline solution, 0.9% NaCl
Nothing by mouth
Nasogastric tube
Foley catheter
Blood pressure monitor, Pulse oximetry, Cardiac monitor
General, Chest, Heart, Abdomen, Rectal ± Others
Abdominal X-ray, acute series, Morphine, IV access, Normal saline
Advance to abdominal X-ray.
Abdominal CT scan, CBC, PT/PTT, BMP, LFT, Amylase, Lipase,
ECG, Troponin
Advance to abdominal CT.
Consult surgery, Pantoprazole sodium, Metronidazole, Gentamicin,
Type and crossmatch, blood, Nasogastric tube, Foley catheter
Advance to surgical consult and case end.
Urea breath test
55
5—ABDOMINAL PAIN
Case #20
Location: Emergency Department
Chief Complaint: Abdominal pain in the left upper quadrant
Case introduction
Initial vital signs
Initial history
• A 22-year-old white man returns to the emergency department for worsening
abdominal pain 1 day after leaving against medical advice.
• Respiratory rate: 23/min
• Blood pressure, systolic: 110 mm Hg
• Blood pressure, diastolic: 70 mm Hg
• The patient returns to the emergency department with worsening abdominal
pain 1 day after leaving against medical advice. He was assaulted outside a
bar yesterday after a night of heavy drinking and left the emergency department before completion of evaluation. The abdominal pain is a dull, constant
ache located in the left upper quadrant, rated as an 8 on a 10-point scale.
Acetaminophen provides only minor relief of the pain.
• Past medical history is unremarkable.
• He smokes one pack of cigarettes a day for the past 3 years and drinks 8 to
10 beers on weekends.
• Family history and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Pulse oximetry
Exam
• General, Skin, HEENT, Chest, Heart, Abdomen, Rectal, Extremities, Neuro
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
98% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in moderate distress.
HEENT/Neck
Bruises on the side of the head. Vision normal. Eyes, including funduscopic
examination, normal. Hearing normal. Ears, including pinnae, external auditory
canals, and tympanic membranes, normal. Nose and mouth normal. Pharynx
normal. Neck supple; no masses or bruits; thyroid normal.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically with
respiration. No abnormality on percussion or auscultation.
Abdomen
Several abdominal bruises. Bowel sounds normal; no bruits. Left upper quadrant
tender to palpation. No hernias.
Extremities/Spine
Multiple bruises and healing superficial scrapes on the arms, legs, and back. No
edema. Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
56
II—CCS CASES BY CHIEF COMPLAINT
Case #20: Splenic Hematoma
Keys to Diagnosis
■
■
■
Look for young patient with recent history of trauma presenting with abdominal pain in the
left upper quadrant.
Examination may show left upper quadrant tenderness and other signs of trauma.
A FAST ultrasound may be ordered initially to rule out peritoneal bleed. Abdominal CT
is test of choice for evaluating the spleen and may show hematoma, fluid accumulation, or
rupture. A CBC should be ordered to evaluate for significant blood loss. Baseline labs: BMP,
PT/PTT, troponin, LFT, amylase, urinalysis.
Management
■
■
■
Most patients can be managed conservatively if they have stable vital signs, stable hemoglobin,
and low-grade injury on CT and are younger than 55 years.
Admit to ICU if hemodynamically unstable or if >3 cm splenic laceration or >50% subcapsular hematoma.
Surgical consult should be routinely obtained. Type and crossmatch, blood for potential
transfusions.
OPTIMAL ORDERS
DIAGNOSIS
• Exam: heart, lungs, abdomen,
extremities
• FAST ultrasound
• Abdominal CT scan
• CBC
THERAPY
LOCATION
•
•
•
•
•
•
•
TIMING
•
SEQUENCING
Orders
Exam
Orders
Clock
Orders
MONITORING
ADDITIONAL ORDERS
• Exam: additional
• PT/PTT
• BMP
• Troponin
• Amylase
• LFT
• Urinalysis
• Intravenous access
Normal saline, 0.9% NaCl
• Oxygen
Morphine
Consult, general surgery
• Advise patient, no smoking
Type and crossmatch, blood
• Advise patient, limit alcohol intake
• CBC daily
Blood pressure monitor
Pulse oximetry
• Abdominal CT scan follow-up
If patient not taken to surgery, admit to inpatient unit or ICU, depending on
severity.
Diagnosis and management should be instituted within 2 hours of simulated time.
Clock
Orders
Clock
Location
Clock
Orders
Clock
End Orders
Blood pressure monitor, Pulse oximetry
General, Heart, Lungs, Abdomen
FAST Ultrasound, Morphine, Normal saline
Advance to ultrasound result.
Abdominal CT scan, CBC, BMP, PT/PTT, Troponin, Amylase, LFT,
Urinalysis, Type and crossmatch, blood
Advance to Abdominal CT scan result.
Consult, general surgery
Advance to consult
Change to inpatient unit or ICU depending on severity.
Advance to additional results and patient updates.
Advise patient no smoking, Advise patient limit alcohol
Advance to additional updates and case end.
CBC, Abdominal CT scan as follow-up.
57
5—ABDOMINAL PAIN
Case #21
Location: Office
Chief Complaint: Abdominal discomfort and malaise
Case introduction
Initial vital signs
Initial history
• A 39-year-old African-American man presents to the office with a 3-week history of abdominal discomfort and malaise.
• Temperature: 38.0 degrees C (100.4 degrees F)
• Blood pressure, systolic: 116 mm Hg
• Blood pressure, diastolic: 72 mm Hg
• The patient describes abdominal discomfort that is predominantly in the
left lower quadrant and is crampy. The pain is partially relieved with bowel
movements and is rated 5 on a 10-point scale. He has had mild nausea and
vomited once 2 days ago. He had one episode of shaking chills last night. He
has not had a bowel movement in 2 days. His diet consists mainly of fast-food
meals.
• Past medical history is unremarkable.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Exam
• General, Skin, Lymph nodes, HEENT, Chest, Heart, Abdomen, Rectal, Extremities
Initial Results: Advance to results of physical exam
Physical Exam Results (Pertinent Findings)
General
Well developed, well nourished; in mild distress.
Skin
Normal turgor. No nodules or other lesions. Hair and nails normal.
Lymph nodes
No abnormal lymph nodes.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds reduced. Left lower quadrant tenderness with guarding. Liver
and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; Occult blood
positive.
Extremities/Spine
Extremities symmetric without deformity, cyanosis, or clubbing. No edema.
Peripheral pulses normal. No joint deformity or warmth; full range of
motion. Spine examination normal.
What is the suspected diagnosis, and what are the next steps in management?
58
II—CCS CASES BY CHIEF COMPLAINT
Case #21: Acute Diverticulitis
Keys to Diagnosis
■
■
■
Look for a patient with abdominal pain, usually in the left lower quadrant, that is crampy
and associated with a change in bowel habits. Other symptoms include nausea, vomiting,
flatulence, and bloating.
Abdominal exam may show mild tenderness in simple diverticulitis, a mass if abscess is present, or rebound tenderness and guarding if peritonitis is present.
The diagnosis is usually based on history and exam. Abdominal CT confirms the diagnosis,
which may also show abscess, fistula formation, and obstruction.
Management
■
■
For uncomplicated diverticulitis: 7 to 10 days of oral antibiotics (e.g., ciprofloxacin +
metronidazole) plus clear liquid diet.
For complicated patients (severe pain, peritonitis, immunocompromised, comorbidities):
admit to inpatient unit, NPO, IV fluids, morphine, start IV antibiotics (e.g., monotherapy
with piperacillin/tazobactam or combination metronidazole + cefotaxime). Surgical consult
if abscess present for drainage.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
• Exam: abdomen, rectal
• Abdominal CT scan
THERAPY
• Antibiotics (e.g., metronidazole, IV +
cefotaxime, IV)
• Consult, general surgery
•
•
•
•
•
•
•
•
•
•
•
•
MONITORING
•
•
•
•
LOCATION
TIMING
SEQUENCING
CBC
Blood culture
BMP
LFT
Urinalysis
Urine culture
PT/PTT
Intravenous access
Normal saline, 0.9% NaCl
Nothing by mouth
Morphine
Type and screen, blood
Temperature
Vital signs
If patient presents in office, admit to inpatient unit if complicated diverticulitis.
Diagnosis and management should be instituted within 2 hours of simulated time.
Exam
Location
Orders
Clock
Orders
Clock
Exam
Orders
Clock
End Orders
Heart, Lungs, Abdomen, Rectal ± Others
Change to inpatient unit
Blood pressure monitor, Abdominal CT scan
Advance to abdominal CT scan results.
Consult general surgery, Intravenous access, Normal saline, Nothing
by mouth, Antibiotics (Metronidazole+ Cefotaxime), CBC, BMP, LFT,
Urinalysis, Urine culture, Blood culture, PT/PTT, Type and screen
blood
Advance to obtain results and patient updates.
Abdomen + Others
Counsel patient, Reassure patient
Advance to additional updates and case end
None
59
5—ABDOMINAL PAIN
Case #22
Location: Emergency Department
Chief Complaint: Generalized abdominal pain
Case introduction
Initial vital signs
Initial history
• A 63-year-old Latino man is brought to the emergency department by ambulance for severe abdominal pain that began 30 minutes ago.
• Temperature: 37.0 degrees C (98.6 degrees F)
• Pulse: 120 beats/min
• Respiratory rate: 34/min
• Blood pressure, systolic: 104 mm Hg
• Blood pressure, diastolic: 62 mm Hg
• The patient woke from an afternoon nap with severe, generalized abdominal
pain that is poorly localized. The pain is constant and not relieved by any
change in position. The pain is rated 10 on a 10-point scale. He experienced
nausea and one episode of vomiting with the pain. He has never experienced
this type of pain before.
• Past medical history of hyperlipidemia and coronary artery disease treated with
medications.
• Family history, social history, and review of systems are unremarkable.
INITIAL MANAGEMENT
Orders
• Blood pressure monitor, Cardiac monitor, Pulse oximetry
Exam
• General, Chest, Heart, Abdomen, Rectal
Initial Results: Advance to results of physical exam
Results (Pertinent Findings)
Pulse Oximetry
94% on room air
Physical Exam Results (Pertinent Findings)
General
Well developed man in acute distress, holding his abdomen.
Chest/Lung
Chest wall normal. Diaphragm and chest move equally and symmetrically
with respiration. No abnormality on percussion or auscultation.
Heart/Cardiovascular
S1 and S2 normal. No murmurs, rubs, gallops, or extra sounds. Central and
peripheral pulses normal. No jugular venous distention. Blood pressure
equal in both arms.
Abdomen
Bowel sounds mildly hyperactive; no bruits. No masses, rebound tenderness
or guarding. Liver and spleen not palpable. No hernias.
Rectal
Sphincter tone normal. No masses or abnormality. Stool brown; occult blood
positive.
What is the suspected diagnosis, and what are the next steps in management?
60
II—CCS CASES BY CHIEF COMPLAINT
Case #22: Mesenteric Ischemia
Keys to Diagnosis
■
■
■
Classic presentation is severe, acute abdominal pain that is poorly localized. Additional
symptoms include nausea, vomiting, and diarrhea.
Abdominal examination is characteristically normal in the face of severe pain. Occult blood
may be present.
Abdominal CT is the test of choice to evaluate for acute ischemia. Abdominal X-ray may be
performed initially to rule out perforation and free air. Serum lactate is usually elevated.
Management
■
■
■
■
ABCs (intubation if needed).
Morphine for pain relief, broad-spectrum antibiotics (e.g., metronidazole + gentamicin).
Nasogastric tube to evaluate for the presence of blood and relieve distention secondary to
ileus.
Surgical consult; type and crossmatch, blood.
OPTIMAL ORDERS
ADDITIONAL ORDERS
DIAGNOSIS
•
•
•
•
THERAPY
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
MONITORING
LOCATION
TIMING
SEQUENCING
Exam: Abdomen
Abdominal X-ray, acute series
Abdominal CT scan
Lactate
CBC
BMP
LFT
Amylase
Lipase
Blood culture
Intravenous access
Oxygen
Nasogastric tube
Foley catheter
Nothing by mouth
Normal saline solution, 0.9% NaCl
Morphine, IV
Consult, surgery, general
Type and crossmatch, blood
Gentamicin, IV
Metronidazole, IV
Blood pressure monitor, continuous
Pulse oximetry
Cardiac monitor
Initial management in emergency department with subsequent transfer to
surgery, ICU, or inpatient unit depending on the case.
• Diagnosis and management should be instituted within 2 hours of simulated
time.
Orders
Exam
Orders
Clock
Orders
Clock
Orders
Clock
End Orders
Blood pressure monitor, Pulse oximetry, Cardiac monitor
General, Chest, Heart, Abdomen, Rectal
Abdominal X-ray, acute series, Morphine, Intravenous access,
Normal saline
Advance to X-ray results.
Abdominal CT scan, CBC, BMP, LFT, Amylase, Lipase, Blood
culture, Urinalysis
Advance to CT scan results.
Consult, surgery, Type and crossmatch, blood, Nothing by mouth,
Gentamicin, Metronidazole, Nasogastric tube, Foley catheter
Advance to surgical consult, additional results, and case end.
None
5—ABDOMINAL PAIN
61
Abdominal Pain—Key Points
■
■
■
■
Abdominal pain is commonly tested on the CCS. Expect one or more CCS cases of a
patient presenting with abdominal pain.
In most cases, the diagnosis should be evident from the history and initial examination.
Additional diagnostic studies should confirm the suspected diagnosis and rule out other
diagnoses.
Some general rules to follow in patients with abdominal pain:
■ If vital signs are abnormal, begin with monitoring orders.
■ If the patient is in acute distress, perform only a limited physical exam.
■ If the patient is a reproductive-age woman, check urine hCG and avoid CT for ultrasound if possible.
■ If the patient is in severe pain, order pain relief early.
■ Do not order surgical consult too early. A surgical consult may not do anything if you
order that up front but may take the patient to surgery after you have confirmed the
diagnosis.
In patients who present acutely, when the clock is advanced, patient update screens will
happen fairly quickly to help you determine whether you are managing the patient correctly.
If you get a negative update on a patient, reevaluate whether your suspected diagnosis is
correct.