Monday, April 27, y

Introduction to Clinical Medicine

SCENARIO 1:
Multidrug therapy
The scenario presents a patient with hypertension, type 2 diabetes and
new symptoms of dry cough and shortness of breath. The student
should identify the cause of new symptoms, implement the new
treatment, and check whether currently used treatment is appropriate.
Proper management includes collect medical history and physical
examination of the patient, order and interpret additional tests, make
the diagnosis of bronchial obstruction and the inclusion of appropriate
treatment.
List of medications to prepare by students prior to the lab:
carvedilol
acetylsalicylic acid
hydrochlorothiazide
enalapril maleate
potassium chloride
metformin
estazolam
ibuprofen, paracetamol, ketoprofen, tramadol
clarithromycin, amoxicillin /clavulanic acid
Salbutamol nebuliser solution
Hydrocortisone
Magnesium sulfate
Theophylline
Budesonide
500 ml multielectrolyte fluid
- 80 years
- kristina
- severe shortness breath
- ER b/c breathing problem starting in morning
- dry, exhausting cough
- carvedilol 6.25
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Monday, April 27, y

- acetylsalicylic (aspirin) 75 mg
- hydrochlorothiozide 25 mg
- enalapril maleate 5 mg (2 xs/day)
- potassium chloride
- metformin 2xs a day 500 mg
- pain killers taken on own:
ibuprofen 200 mg
paracetamol 500 mg
ketoprofen 100 mg
tramadol 100 mg
- clarithromycin 500 g ended 2 days ago; amoxicillin & clavulanic acid 850 +
150 mg ended 2 days ago
1. give oxygen
2. Breathing problem
1. auscultate patient: heard wheezing and restriction
2. had constriction so give a bronchodilator
3. should elevate bed = easier to expand lungs
3. heart rate was high
4. concerns about heart failure, reactions to new medications, pneumonia
not cured
5. PROBLEM:
1. enalapril: ACE inhibitor --> prevents break down of bradykinin and
produces cough
2. carvedilol: non-selective beta blocker --> constriction of lungs
6. give oxygen, auscultate, bronchodilator & raise bed, re-assess and
auscultate again to check is breathing improves

Monday, April 27, y

7. KNOW EVERYTHING ABOUT PT. MEDICATION

SCENARIO 2:
Injuries - care and treatment
The scenario presents a patient after an injury of the hip additionally
with persistent atrial fibrillation. The student has to exclude fractures
and apply appropriate analgesic therapy. Proper conduction includes
collecting medical history and physical examination of the patient,
ordering and interpretation of diagnostic imaging studies, injury
management and to formulate a course of treatment.
List of medications to prepare by students prior to the lab:
Acenocumarol/warfarin according to INR
Bisoprolol fumarate
Enalapril maleate
potassium chloride
Dipyron hydrate, Methapyrone, Metamizol
Tramadol [Ultram, Ralivia flashtab, Ralivia ER, Tramal]
Ketoprofen [Orudis, Profenid, Actron, Oruvail]
Paracetamol [Tylenol, APAP, Datril, Acetaminofen]
500 ml r-r Ringers or Multi electrolyte fluid (Isolyte)
Patient: slippery sidewalk, 86 year old woman slipped and fell on right hip on
curb, wound on R. hip, little bit elevated HR, feels pain on r. hip and brought
to ER
1. stop bleeding and check vitals
1. HR = very high >160
2. BP high
due to pain
2. give painkillers; always assess id successful or not by asking pt. grade 1 10 before & after the medication (remember to give dosage accordingly
to age)
1. normal to become sleepy after morphine; start at 2mg and then assess
and adjust dose accordingly to avoid them becoming unconscious
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Monday, April 27, y

2. check saturation and respiratory rate because opioids can cause
suppression of respiratory system
3. give oxygen mask to continue oxygenate patient
4. reverse opioid excess with naloxone
3. X Ray to see if fracture or not; if fracture don't move leg
4. Clean the wound and for infections
1. give antibiotics (IV) incase of bacterial infection before suturing; give
oral dose later to take at home
2. give antivirals (IV) incase of viral infection; ex. incase of rabies, check
tetanus status
5. pt. had been taking warfarin which increased bleeding; reverse this effect
1. give fresh frozen plasma
2. vitamin K
***always check for allergies to medications; ex. ibuprofen and aspirin
allergies
- give a small amount and check for allergic reaction before admin full
dose

SCENARIO 3:
Rating respiratory and circulatory condition of patients,
preoperative assessment
The scenario presents a patient being prepared for elective left knee
replacement surgery. The patient had myocardial infarction 5 years
ago, suffers from recurrent venous thromboembolism, takes
anticoagulation from 8 months, 9 months ago the patient was
implanted pacemaker system due to third-degree atrioventricular
block. In addition, the patient has hypertension and chronic obstructive
pulmonary disease.

Monday, April 27, y

List of medications to prepare by students prior to the lab:

Budesonide suspension for nebulizer [Pulmicort turbuhaler]

Acenocumarol /warfarin according to INR (2,5)
metoprolol (Lopressor, Toprol XL)
ramipril (Tritace ,Vivace )
pentaerythritol tetranitrate
enoxaparin sodium injection (Lovenox)
Fraxiparine
Furosemide
Metamizol/paracetamol/ tramadol
Potassium chloride
Cefazolin /powder for injection/ (Tarazolin)
Midazolam [Dormicum, Hypnovel,Versed]
knee replacement surgery
MI and angioplasty
pace maker 6 months ago b/c 3rd degree av block of heart
hypertension and chronic obstructive pulmonary disease
decide if possible to do surgery the next day
pacemaker is fine in surgery; only defibrillator needs to be turned off
high BP (151/103);
Drugs:
- budesonide suspension for nebulizer 320 ug 2xs a day
- acenocumarol / warfarin according to INR (2.5)
- metoprolol (lopressor, toprol XL) 50 mg
- ramipril (tritace, vivace) 10 mg
increased b/c high BP
- penterythitol tetranitrate -1 tbl (20 mg 3x/day sublingually)
saturation level was low!
wheezing was heard

Monday, April 27, y

- assess respiratory system and then medication should have been
changed
spirometry: to check tidal volume; if very low then patient won't be able
to come off anesthesia to breathe on own
x ray of chest should have been done
re-assess clotting factors after stoping warfarin in 3/4 days
- give heparin instead b/c lower duration of action and less risk for
surgery

SCENARIO 4:
Analgesic therapy
The scenario presents a patient who came to the Hospital Emergency
Department because of severe pain of the lower back and numbness of
the right lower limb. The student should order analgetic treatment,
diagnose the cause of acute pain, to administrate long-term analgesia
and refer the patient to the appropriate treatment. Proper conduct
includes medical history, physical examination of the patient,
administration of an appropriate analgesic treatment, order diagnostic
imaging studies, diagnosis of disc herniation of the nucleus pulposus
protrusion at the lumbar spine and referring the patient to the
Neurosurgical Clinic for treatment.
List of medications to prepare by students prior to the lab:

Ketoprofen
0,9% NaCl 500ml
Tolperisone
Tramadol
severe back pain suddenly appeared when tried to move book case
acute piercing stabbing pain radiating to back of both legs
has problem with moving legs
40 years old and is conscious

Monday, April 27, y

X-Ray: bones visualized and all was fine
CT/MRI: visualize spinal cord & nucleus pulposus
- CT = faster thus better in acute situations and patient presents right
after injury
- MRI = 40 minutes thus everything may change; do it if you have time
L3/4 and L4/5 nucleus pulposus is affected
elevated leg to see if suddenly pain appears; if can arise leg very high
pressing on nerves is not very severe but if only arise small amount must
be a huge compression of the nerve
@ home took 100mg ketoprofen (NSAID)
gave morphine in hospital
trying not to breath to exacerbate pain thus shallow breathing

SCENARIO 5:
Intensive medical care for an elderly person
The scenario presents the unconscious patient breathing
spontaneously. The student should to protect the patient's airway, get
the stabilisation of the patient's cardiovascular parameters and direct
the patient to the appropriate ward. Proper conduct includes
monitoring of the patient, intubation, administration of drugs to lower
BP and HR, laboratory tests and diagnostic imaging studies, and
directing the patient to the Department of Neurology.
List of medications to prepare by students prior to the lab:

Metoprolol 1mg/ml (5 ml)

Amiodarone
20% Mannitol 250 ml
fresh frozen plasma (FFP),
0.9% Sodium Chloride (normal saline)
pt = 76
unconscious patient breathing on own

Monday, April 27, y

reports headache and at dinner lost consciousness and fell to ground
ambulance brought to ER
family tells has some sort of heart problem for many years
had cold for many days and was using some home remedies like aspirin
& garlic in large quantities
why did he fall unconscious
- decreased oxygen to brain
check his pupils: one pupil was dilated thus stroke
CT scan to see what part of brain was affected
- lot of blood in ventricle and subarachnoid space
- no surgical possibility according to neurosurgeon
- increased pressure in skull => may lead to compression of brain stem
and thus heart and respiratory problems
- decrease the pressure by giving 20% mannitol with furosemide
mannitol moves water back into veins and then the diuretic will
move the fluid into the urine
would decrease the BP enough
- should raise head of pt to help with drainage from head
Glasgow coma scale = 3; anything less than 8 intubate
high heart rate = more dangerous
- working very fast and not getting enough oxygen thus leading to
infarction
- give beta blocker (selective type)
BP should be higher in order to perfuse the compressed vessels in the
brain
monitor and control the vitals as well as intracranial pressure

Monday, April 27, y

**** treat patient first
do full trauma CT

SCENARIO 6:
Prevention and treatment of delirium
The scenario presents alcohol abused patient, after an episode of
bleeding from the upper gastrointestinal tract. The student has to
assess the loss of blood, exclude cranio-cerebral injury, make up
deficiencies and refer the patient to the appropriate department.
Proper procedure includes taking a laboratory tests, diagnostic imaging
study of the head, adequate hydration of patients, supplementing
electrolytes, Vitamin K and RBC. Subsequently, after obtaining a
negative result for the presence of alcohol in the blood, turn
neuroleptic treatment and transfer to the Department of
Gastroenterology.
List of medications to prepare by students prior to the lab:
phospholipid essential (Essentiale Forte) 2 caps x 3
Pantoprazole (Controloc) 20 mg x 1
phytomenadione (Vitacon) 10 mg x 1
Potassium chloride x 1
1000 ml multielectrolyte solution (Isolyte)
500 ml Voluven (6% hydroxyethyl starch 130/0.4 in 0.9% sodium
chloride injection)
Ephedryne
2 j PRBCs (packed red blood cells)
Haloperidol
rescue team brings in patient b/c blood vomiting and loss of
consciousness in front of house
lack logical contact
can smell alcohol on patient
pale and sweaty skin
marks of blood clots in angles of mouth
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Monday, April 27, y

60 years old
esophageal varices ruptured; perhaps b/c of alcoholic
help patient when vomiting to remove it, should move patient on to side
check level of alcohol in blood and assess type of alcohol consumed
- if consumed methanol; could cause blindness and later death
BP was low; loss of blood via vomit and should lab test for hemoglobin,
CBC, level of RBCs
- Hb = 6 (far too low)
- give blood transfusion b/c huge loss; don't give just fresh frozen
plasma in this case (is good for bleeding b/c has albumin and clotting
factors)
wall of stomach was thick = could be due to cancer as a result of
alcoholism
vomiting = loss of electrolytes as well

SCENARIO 7:
Rehabilitation after surgery
The scenario presents a patient after surgery, arthroplasty of the right
hip. The patient reported severe pain of the right hip after falling down.
The student is to conduct the medical history and physical
examination, give analgesics and perform the necessary tests. Proper
action (based on research) includes directing patient to the
Department of Orthopaedic for the operation and further rehabilitation.
List of medications to prepare by students prior to the lab:

Acenocumarol due to INR

Bisoprolol 5 mg x 1
Enalapril 10 mg 2x1
Potassium chloride
Ketoprofen
500 ml 0,9% NaCl (Normal Saline)
Tramadol

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Monday, April 27, y

Metamizol
Paracetamol (acetaminophen)
brought by ambulance to ER
found injury of right hip because of fall
broken femoral neck
had surgery to fix it
one hour post-op; decide if everything is okay with patient
- has epidural anesthesia and asking why can't move legs
BP 140/90 usually
after surgery check wound and do physical examination
bandage was dry and BP was low but high HR
- treat the BP first
blood testing: CBC, Hb, hematocrit, ferritin, electrolytes
give saline solution
wait a few hours before giving anticoagulant because epidural and
wound needs coagulation

SCENARIO 8:
Anatomical and physiological processes associated with aging
The scenario presents conscious patient suffered dysarthria, paresis of
the upper and lower left limbs. The student should take care of the
patient properly, diagnose the cause of the deterioration of his
condition. Proper conduct includes: monitoring, neurological
examination, diagnostic imaging studies and adequate treatment.
List of medications to prepare by students prior to the lab:
Clopidogrel (Plavix) 75 mg
Acetylsalicylic acid (Acard/Aspirin) 150 mg
Ramipril (Vivace) 5 mg
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Monday, April 27, y

500 ml 0,9% normal saline (NaCl)

Nootropil (Piracetam) tabl. 1,2 g x 2
Antihypertensive therapy (diuretics and ACE-inhibitors)
statins in the reduction of LDL less than 100 mg % [ mg / dl ] - e.g. 20
Zocor (simvastatin) x once in the evening
anticoagulants (per os) - Warfarin - recommended the INR should be
2-3
conscious pt
came in b/c abdominal pain, diarrhea and weakness
sigmoid colon resected
- 3 courses of chemotherapy
3 months after last course
has metastases in liver, lungs, and abdominal lymph nodes
feel pain and is very weak
80 years old
very low oxygen and BP with high HR
- gave oxygen and fluids
BP did not rise enough
HR increased further
terminal patient: metastases, pain, etc.
- give opioids to relieve pain
- can only control vitals and pain
heart stopped because of illness
- check pulse and if none start CPR chest compressions
- may revive but will have complications again in future
- check for DNR!
if none then start CPR; if asystole will be very hard to revive
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Monday, April 27, y

if not responding to CPR consider stopping after 3 cycles as pt is
terminal

SCENARIO 9:
Acute abdominal pain
The scenario presents a patient with patient with acute abdominal
pain, nausea and difficulties with breathing. The student should
identify the cause of symptoms, implement the treatment. Proper
management includes collect medical history and physical examination
of the patient, order and interpret additional tests, make the diagnosis
of abdominal pain and the inclusion of appropriate treatment.
List of medications to prepare by students prior to the lab:

oxygen
acetylsalicylic acid
nitroglicerin
morphine
500 ml multielectrolyte fluid
acute abdominal pain, nausea and difficulty breathing
- started 30 min ago during physical activity
40 years old
first time in life feeling this pain
recent MI
- do lab work for CBC, troponin, CK-MB, etc.
- do physical for hernia and other abnormalities in abdomen
- elevated CK-MB
- ST elevation of monitor
do full 12 lead ECG
AvF, V5, V6 = inferior wall affected => abdominal pain

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Monday, April 27, y

- give nitroglyerin for pain
continued pain give morphine
- give aspirin
- give oxygen if low send for angiography

SCENARIO 10:
Acute pain in the lumbar region
The scenario presents a patient with patient with patient with acute
pain in the lumbar region. The student should identify the cause of
symptoms, implement the treatment. Proper management includes
collect medical history and physical examination of the patient, order
and interpret additional tests, make the diagnosis of pain and the
inclusion of appropriate treatment.
List of medications to prepare by students prior to the lab:

Codeine/acetaminophen
500 ml multielectrolyte fluid
Doxazosin
Tamsulosin

Nifedipine (Procardia, sustained release)

feels acute lumbar pain for 2 hours
found fresh blood in urine
increased BP and HR
assess pain on 1-10 scale
- give codeine for pain
- re-assess pain level
did USG and found bilateral stones
- 10 mm stone needed to get it to pass and breakdown

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Monday, April 27, y

- 5 mm may just pass
- do CT because not always sure if correct
around stone is constriction of the muscles; give muscle relaxants (alpha
blocker)
give fluids to help small stones pass in urine

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