Initial orders (4) on a 40 year old woman at clinic with weakness, fatigue, depression, orthostatic hypotension, skin hyperpigmentation, weight loss, anorexia x 8 months?
Follow-up, diagnostic orders (2.)?
- think Addison disease aka chronic adrenal insufficiency*
1) orthostatic vital signs
2) ECG
3) CBC
4) BMP (should show hyperkalemia)
- Early morning cortisol level (IF LOW/undetectable, diagnostic of Addison. If Intermediate, go to step 2)
- ACTH (cosyntropin) stimulation test (ACTH given, cortisol measured at 0, 30, & 60 min. If cortisol remains low, diagnostic of Addison. If cortisol increases at 30/60min, it’s pituitary or hypothalamic dysfxn/secondary hypoadrenalism
Treatment (3) for Addison disease?
1) fluid replacement (b/c usually orthostatic hypotension)
2) hydrocortisone
3) fludrocortisone
Initial orders (3) on a 36 year old year old woman at clinic with dysmenorrhea, loss of peripheral vision/increased car accidents, nipple discharge?
Follow-up/treatment (2.)?
- think prolactinoma/pituitary adenoma > pregnancy > primary brain tumor*
1) urine pregnancy test
2) prolactin level
3) brain MRI
- bromocriptine or cabergoline (dopamine agonist)
- consult neurosurgery re: possible surgery (not always done)
Differential diagnosis for person with altered mental status brought to ED (mnemonic)?
AEIOU TIPS: Acidosis Electrolytes, Encephalopathy, Endocrine (DKA, HOHC) Insulin(-->hypoglycemia) Opiates/OD Uremia Trauma, Thermia (hypo/hyper), Toxemia Infections PE, Psychogenic Space-occupying lesions, Shock, Seizure
Initial orders (9) on a patient brought to ED with AMS?
1) CBC
2) BMP
3) serum ketones
4) U/A
5) VBG or ABG
6) ECG
7) Portable CXR
8) Urine Toxicology
9) IVF
Patient comes to ED with hyperglycemia, urine ketones, +anion gap: what are your first steps in management(3)?
While monitoring, what are the (2.) steps to remember to add/change things during management?
- think DKA*
1) rapid IVF + potassium (only if K+ <5.5)
2) regular insulin IV drip (only start if/when K+ >3.3)
3) admit to ICU
- when glucose (via repeating fingerstick glucose) falls < 250, add glucose to IVF
- when acidosis (via repeating VBG, BMP) and ketosis (via repeating serum ketones) resolves, STOP insulin drip and transition to SC insulin
Initial orders (3) on a 28 year old woman coming to clinic with fatigue, dry skin, weight gain, constipation, hair loss x 4 months?
Follow-up orders (2.) for diagnosis?
- think hypothyroidism ie. Hashimoto, deQuervain, Reidel > depression >anemia*
1) CBC
2) BMP
3) TSH (should be increased)
- free T4 (should be decreased)
- T3
Initial orders (2) on a 25 year old woman coming to clinic with tremor, weight loss, palpitations, diaphoresis, decrease in appetite x 3 months?
If one of the above orders is low, what are follow-up orders (2.)?
If one of the above orders is normal, what are the follow-up orders (#2)?
- think hyperthyroidism (Graves, toxic mult goiter, toxic adenoma, deQuervain, Hashitoxicosis-early in dz, exogenous, etc), anxiety/panic, pheochromocytoma, stimulant abuse*
1) ECG
2) TSH
If TSH low/undetectable: 1. free T4 2) T3
If TSH normal: #1) 24 hr urine metanephrines #2) urine toxicology screen
Management (2 +/- 3) for diagnosis of hyperthyroidism?
1) Propanolol (symptomatic relief)
2) methimazole or propylthiouracil
+/- 3) anti-TPO Antibodies
+/- 4) thyroid uptake scan (diffuse in Graves, mult nodules in tox mult goiter, no update with thyroiditis/exogenous)
+/- 5) endocrinology referral for radioactive iodine ablation
Initial orders (6) on a 41 year old woman with HTN + DM on HCTZ, metformin, amlopidine, glipizide coming to clinic with fatigue, insomnia, hirsutism, central abdominal weight gain, stretch marks, dysmenorrhea, HTN x 2 months?
- hypercortisolism (exogenous, ACTH-producing, or adrenal) > depression, metabolic syndrome*
1) CBC
2) BMP
3) urine b-HCG
4) CK
5) urinalysis
6) 24 hour urine free cortisol (should be increased) OR salivary cortisol (should be increased) OR dexamethasone suppression test
If low dose dexamethasone suppression test shows no suppression and high dose shows suppression, what does this mean and what are the follow-up actions(3) to diagnosis & management?
- suspect ACTH-producing pituitary tumor (Cushing disease)– dexa at high doses will do negative feedback on ACTH in pituitary, but NO effect on ectopic ACTH tumor or adrenal adenoma)*
1) ACTH (should be increased only in pituitary tumor & ectopic ACTH tumor, & with high dose dexa supression you know it’s pituitary)
2) brain CT/MRI (should show pituitary mass)
3) neurosurgery consult for transsphenoidal surgery
Initial orders (6) on 51 year old obese man with no PMHx presenting to clinic, fasting, after getting blood glucose of 290 measured at health fair?
- suspect T2DM*
1) fingerstick blood glucose
2) BMP
3) CBC
4) HgA1c
5) U/A
6) fasting lipid panel (if LDL <100, start statin // <70 when concurrent +CVD)
Follow up actions (5) on 51 year old obese man with no prior MHx, at clinic with mild nonproliferative diabetic retinopathy on fundoscopic exam and new findings of fingerstick blood glucose 200, HgA1c 7.9%, LDL 65, U/A with moderate glucose and trace protein?
1) Diabetes counseling (i.e. check feet daily for ulcers)
2) Lifestyle modification - diet and exercise
3) Metformin (& f/u in 3 months, remeasure A1c)
4) urinary microalbumin (*if increased, start ACE-i EVEN if no HTN!!)
5) Ophthalmology referral for retinal photography
Initial orders and management (8) on 52 year old white woman, smoker, with no PMHx who comes to clinic with 3rd measurement of elevated BP despite changing diet & exercise?
- suspect essential HTN > hyper/hypothyroidism > pheochromocytoma, RAS*
1) CBC
2) BMP
3) U/A
4) TSH
5) lipid panel
6) ECG
7) thiazide diuretic (& f/u in 1 month. If unresolved, add 2nd agent: ACE-i/ARB/CCB/BB)
8) counseling smoking cessation, diet, exercise
Initial orders (7) on 60 year old woman presenting to ED after being referred by PCP for constipation, nausea, memory deficits x 5 months, and hypercalcemia on labs?
- suspect hypercaclemia d/t PTH or malignancy > hyperthyroid, meds, milk alkali syndrome, immobilization
1) CBC
2) CMP
3) ECG
4) PTH (can get as initial order b/c already had hypercalcemia on labs)
5) ionized Ca+2
6) albumin
7) ECG
Management (5) of 60 year old woman at ED with Ca+2=13.6(high), PTH=55(high-normal), normal albumin, ECG showing short QT interval?
- primary hyperparathyroidism*
1) IVF
2) calcitonin
3) bisphosphonate
4) sestamibi scan or U/S of parathyroid glands (if PTH was low instead of high-normal, you would get CXR/CT or PTHrP to look for primary malignancy as cause of increased Ca+2)
5) surgical consult for parathyroidectomy
Initial orders (6) for 35 year old woman presenting to ED with intense colicky right flank pain somewhat relieved by ibuprofen, & dark urine x 2 days?
- suspect nephrolithiasis, pyelonephritis > MSK pain, cholecystitis*
1) CBC
2) BMP
3) U/A
4) urine b-hCG
5) NSAID (i.e. IV ketorolac or ibuprofen)
6) IV morphine
Imaging to order on patient with suspected kidney stone?
If stone is 3 mm in ureterovesicular jxn, what are f/u actions (4)?
Imaging: NONCONTRAST CT of abdomen/pelvis
1) send home with counseling on disease (i.e. to strain urine at home)[only do urologic consult if concurrent infection with hydronephrosis, renal failure, uncontrollable pain, or inability to tolerate PO]
2) prescription for oral ibuprofen
3) prescription for opioid
4) prescription for oral tamsulosin
Initial orders (4) then secondary/diagnostic orders [5] on an 8 year old boy coming to office with puffy face, high blood pressure, and hematuria x 2 days, history of strep throat 10 days ago?
suspect nephritic syndrome, esp PSGN > IgA nephropathy > HUS
1) CBC
2) BMP
3) coagulation profile
4) U/A w/ microscopy (should be +RBC casts, protein)
1] antistreptolysin O (ASO) titer (should be +)
2] anti-DNAse B titer (should be +)
3] serum C3 level (should be undetectable/low)
4] serum C4 level (should be undetectable/low)
5] nephrology consult (but only renal bx if unclear dx/deteriorating)
Initial orders (5) on a 65 year old man with history of SCLC coming to ED with headache, nausea, weakness, fatigue, muscle cramps x 3 days?
- suspect paraneoplastic syndrome i.e. SIADH causing hyponatremia > brain mets, cachexia/lyte imbalances, hypoglycemia/hyperglycemia*
1) noncontrast head CT
2) fingerstick blood glucose
3) oxygen saturation
4) CBC
5) BMP
Follow-up orders (5) on a 65 year old man with history of SCLC coming to ED found to have Na+=119 on BMP? Treatment [2]?
paraneoplastic syndrome i.e. SIADH causing hyponatremia
1) admit to wards
2) serum osmolality (will be low)
3) urine osmolality (will be high)
4) urine electrolytes (Na+ will be high)
5) serial Na+ checks (after treatment begins)
1] fluid restriction
2] IV NS with correction no faster than 0.5 mEq/L OR NaCl tablets OR vasopressin antagonist i.e. conivaptan
Initial orders (7) on 62 year old man with history of T2DM & ESRD on HD presenting to ED with weakness x 2 days, s/p missing past week of hemodialysis?
- suspect hyperkalemia > fluid overload/CHF, hyperglycemia, hypercalcemia, uremia, anemia*
1) ECG
2) CMP
3) CBC
4) CXR
5) BNP
6) troponin
7) LFTs
Treatment (5) for 62 year old man with history of T2DM & ESRD who missed his HD and was found in ED to have K+=7.4, Cr=12.1, ECG with peaked T waves?
1) Admit to inpatient
2) IV CaCl OR Ca-gluconate
3) IV insulin + glucose AND/OR NaHCO3 + albuterol
4) furosemide AND/OR sodium polystyrene sulfonate
5) nephrology consult for hemodialysis
Initial orders (3) on 72 year old woman, 40 pack yr smoker, coming to clinic with knife-like, non-radiating thoracic back pain with change in posture x 3 weeks?
- suspect compression fracture 2/2 osteoporosis > bone metastasis 2/2 lung ca, Paget disease, hyperPTH*
1) CBC
2) BMP
3) thoracic spine X-ray (+wedge fractures/DJD)
4) Calcium level
5) Vitamin D level
