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Just click on the button below and start downloading it from medicalstudyzone. Google Drive Download Link. Moreover Medicalstudyzone. If you feel that we have violated your copyrights, then please contact us immediately. She is now short of breath and mildly nauseated. She has a history of hypertension for the past 5 years that is being appropriately treated with medication.
There is no history of any previous episodes of chest pain either at rest or on exertion. The absence of fever, chills, cough, or pleural rub suggests that the problem is not an infectious pulmonary process. Physical examination shows hypertension and tachycardia with bounding central and peripheral pulses.
The patient is anxious, diaphoretic, and in severe distress from chest pain. In this case, the sudden onset of radiating chest pain along with the bounding pulses, widened pulse pressure, aortic murmur, and long history of hypertension are highly suggestive of the diagnosis of ascending aortic dissection. Optimal medical therapy would include stabilizing the patient with intravenous IV medications to lower both blood pressure and heart rate. Suboptimal treatment would include other antihypertensive agents.
Lastly, IV narcotic analgesic administration to alleviate pain is important. The patient's cardiovascular status should be monitored with a cardiac monitor or by ordering repeat vital signs.
Some measure of oxygen saturation is also indicated. Once stable, some form of chest imaging that would assess for an aortic dissection including computed tomography CT of the chest with contrast, cardiac computed tomography angiography CTA with contrast, echocardiography, transesophageal echocardiography TEE , magnetic resonance imaging MRI of the chest, or cardiac MRI with gadolinium is needed.
The diagnostic workup should also include blood tests for serum creatinine basic metabolic profile or complete metabolic profile to assess kidney function, electrolytes to check sodium and potassium concentrations, a complete blood count CBC to look for signs of anemia, serum creatine kinase or serum troponin I cardiac enzymes to rule out myocardial compromise, and a blood group and crossmatch.
Once the ascending aortic dissection is discovered and aortic root involvement confirmed, optimal treatment should include open heart surgery, endovascular aortic aneurysm repair EVAR , thoracotomy or cardiothoracic surgery, or general surgery consult. An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first 2 hours of simulated time.
Suboptimal management of this case would include ordering additional physical examination components that would add no relevant information, administering an IV antihypertensive without a beta blocker, neglecting to order indicated blood tests, or a delay in diagnosis or treatment.
It would be suboptimal to order anything unnecessary that would waste time, even if the test or procedure were not invasive or risky eg, lung scan. Examples of poor management would include failure to order any physical examination, failure to order an imaging study that would reveal the dissection, failure to administer an antihypertensive agent, or failure to order surgical intervention.
Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk include:. In this case, a 4-year-old boy is brought to the office because of increasing shortness of breath during the past 3 days. From the chief complaint, the differential diagnosis is broad; however, the comprehensive history narrows it. The patient has been wheezing and has a cough that has been worsening.
The mother says that the wheezing seems to get worse after the patient plays outside but resolves shortly after he comes inside. When the patient was 2 years old, he was hospitalized for 1 week for similar symptoms and treated with intravenous antibiotics and oxygen. At age 18 months, the patient had pressure equalizing tubes inserted.
The patient also has a history of allergy to pollen and atopic dermatitis. Physical examination shows slight tachycardia. Skin examination reveals dry, scaly patches in the antecubital areas. The patient's illness, at this point, would seem most consistent with an obstructive pulmonary disease process.
In this case, the increased coughing and wheezing, as well as the history of frequent respiratory and ear infections, are highly suggestive of the diagnosis of asthma. In this acute presentation, timing is important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first few hours of simulated time. Examples of invasive and noninvasive actions that would subject the patient to unnecessary discomfort or risk, or would add no useful information to that available through safer or less invasive means, include:.
In this case, a year-old woman is brought to the emergency department by her roommate because of lethargy, nausea, and vomiting. From the chief complaints, the differential diagnosis is broad and includes the many causes of acutely altered mental status. However, the comprehensive history narrows the possible differential diagnoses, making uncontrolled diabetes very likely. The patient has been experiencing nausea and vomiting for the past 24 hours and has been unable to eat during that time.
During the past hour, she has become drowsy and lethargic. She has a history of type 1 diabetes mellitus, for which she normally takes insulin multiple times daily. However, she has had no insulin during the past 24 hours. The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension.
Cardiovascular examination shows thready central and peripheral pulses. Skin examination reveals poor turgor. Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses. Taken together, the history and physical examination findings support the initial impression of complications of type 1 diabetes mellitus.
In this particular patient, the history of type 1 diabetes mellitus presenting with prolonged nausea and vomiting and lethargy and drowsiness, combined with the physical examination findings of fever, thready pulses, tachycardia, signs of dehydration, and diffuse abdominal tenderness are highly suggestive of the diagnosis of diabetic ketoacidosis due to infection and inadequate insulin.
Stabilizing the patient with optimal intravenous IV fluids eg, Lactated Ringer solution or normal saline solution to improve hydration, and treating the patient empirically with a broad-spectrum IV or intramuscular IM antibiotic to cover the most likely sources of infection are important. Once the serum glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical.
The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism before administering empiric antibiotics, and serum electrolyte measurements ie, potassium to assess the severity of dehydration.
Serum creatinine or urea nitrogen measurements basic metabolic profile or complete metabolic profile to assess kidney function are indicated. An optimal approach would include completing the above diagnostic and management actions as quickly as possible ie, during the first hour of simulated time. Suboptimal management of this case would include delay in diagnosis or treatment; administering suboptimal IV fluids eg, hypotonic saline solutions, dextrose in water, or dextrose in Lactated Ringer solution ; initial treatment with subcutaneous insulin; suboptimal IV or IM antibiotics; or neglecting to order indicated blood tests.
It would be suboptimal to order unnecessary tests or procedures that would serve no clear diagnostic or therapeutic purpose even if those actions are low-risk. Examples of poor management would include failure to order any physical examination; failure to order a serum glucose test; failure to order a blood culture to determine the cause of the infection or failure to order a blood culture before administering empiric antibiotics; failure to treat with IV fluids, antibiotics, and insulin; or failure to monitor the patient after treatment.
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