My Step 3 Cases:

1. 40ish woman with newly diagnosed DM II
2. Ectopic pregnancy
3. 60ish man with dyspnea: newly diagnosed CHF
4. PUD
5. 30ish woman with Colles fracture – Domestic Violence
6. 9 month old child with FUO (all cultures negative)
7. TCA OD with suicide note (never got better)
8. Adolescent girl with DUB
9. Elderly man with abdominal pain: ischemic bowel

• Ectopic Preg Case: I prepped her for surg (OB consult, coags, Foley, type & cross) but forgot the NPO order. Actually, after U Preg was +, when I did the transvag and abdominal ultrasounds, the mass was only 3x4 and so I thought she could be managed with methotrexate (since it was under 5) but when I got the OB consult, they said they were taking her to surgery!

• CHF case: I started him on Lasix which solved his dyspnea, but I forgot to order KCl and ACE-I as well. I did remember the Echo, EKG and everything, even got a Cards consult (maybe that was overkill). He got better.

• Duodenal Ulcer Case: this man was on long term ASA for arthritis and so I stopped ASA and changed him to celecoxib, then got a colonoscopy (since he had + FOBT and he was older) plus since he had “gnawing pain” and it got better after eating, I knew it was PUD, so I did tests for H. Pylori (all negative) I believe it was after EGD that I saw the ulcer, so I started him on omeprazole, and he got better.

• The Colles fracture: I knew it was a DV case because she came with her husband but he was angry and wanted to leave and on her ROS she had h/o several other injuries and stuff, so I got a social work consult, gave the pt safety counseling (or is it called domestic violence counseling?, can’t remember) and got an Ortho consult (just in case, but they said I should take care of it myself) so I splinted it, not sure if that was correct and gave her NSAIDs. At first nothing happened, but then she finally admitted it was an abusive relationship and agreed to stay with friends, plus her hand got better.

• 9 month old with FUO: I was perplexed because he had been on 2 different ABx with no effect and had a 104 fever and I did pan cultures, blood, urine, even LP and all negative (I did not get a CT before the LP but he didn’t have any signs of ICP so I hope that was ok), anyway, I tried 2 different ABx and by the 2nd one he got better so I D/C’ed him and switched it to PO form.

• The TCA OD was a man who had written a suicide note and empty bottles were found near him, I did UDS (took so long to get results! I guess I should have done serum DS) and Acetaminohpen, BAL and ASA levels but all negative. I had to intubate him because his breathing was so poor and transfer him to ICU and even gave him naloxone but it didn’t work (I think I forgot to DC that at the end, oops) and then finally the UDS came back + for TCAs and just then his wife came in with the empty TCA bottle! I already had him on constant heart and BP monitor and maybe I should have given him something for QT prolongation but I could not remember what drug to give, so I just stabilized him and at the end before the case ended, I order Psych consult even though he was still unconscious, just so they’d know I thought of it. He never got better. Maybe I messed this one up by not treating the QT prolongation? I never did NG lavage or charcoal because he was unconscious the whole time and I had to intubate him and I was not sure if you can do all that on an unconscious pt, for fear of aspiration. I gave him IV fluids, but I cannot remember if I put a Foley on. Is there a Poison Control consult? I did not order one but just thought of it now.

• The girl with DUB also had a h/o sexual promiscuity so I did Pap, and cultures but all were negative. I started her on NSAIDs and OCPs and she got better. I did order UPreg (-), CBC (normal) so I never did coags and all the bleeding factor tests, maybe I should have. I also made sure to give her safe sex counseling. She got better.

• The elderly man with abdominal pain and many risk factors (h/o MI, CHF, a fib) was screaming ischemic bowel to me, so I did abdominal XR and then abdominal angiography which showed the blockage in the SMA, so I got surgical consult and prepped him for OR, and the case ended.

A 19-year-old woman, gravida 2, para 1, at 39 weeks' gestation is admitted in labor. Contractions occur every 2 to 3 minutes. The cervix is 4 cm dilated and 80% effaced. She requests an epidural for pain control. Ten minutes after the epidural is administered, she becomes nauseated and diaphoretic and vomits. Her blood pressure is 60/palpable mm Hg. A fetal heart tracing shows sustained fetal decelerations. The cervix is now 8 cm dilated. The most appropriate next step in management is administration of which of the following?

A ) Ephedrine

B ) Magnesium sulfate

C ) Nifedipine

D ) Oxytocin

E ) Terbutaline