Transcript Archer CCS Workshop

CCS Workshop
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Archer Online USMLE Reviews
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arrive! Thank you!
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CCS Tips
Note the setting (location) of the patient encounter. The setting helps
you decide on the aggressiveness of your treatment orders and
whether to send the patient home. It also gives a clue to the medical
diagnosis.
In the setting of ER, do not waste time if vitals are unstable. If you
are not sure of the medical diagnosis, admit the patient and work
him up. You can always discharge him from the hospital, the next
day.
Write down the age, sex, chief complaint, and allergies of the patient
on the writing sheet provided at the exam. This will help you save
time when considering medical differential diagnosis.
If you did not write it down the important points in History, do not
panic. You can always access it from the Order sheet button. Click
on “Write order” button and then select “Progress notes”. Your
patient’s initial H & P as well as updates are stored under this
section.
CCS Tips
Two “Times” on the software
“Real” time – the time on the bottom of the screen
on the right side.
“Simulated” time – the time on the bottom of the
screen on the left side
“Real” Time
“Real” time – the time on the bottom of the screen on the right side.
You have “25” minutes to complete the case. “20” minutes for active case
management + “5” minute screen.
Real time is not scored. However, if you run out of the real time of “20”
minutes - your “5” minute screen will pop up. Since you cannot do certain
important steps on 5-minute screen, make sure you set your goals on your
case and reach them before the 20 minutes are complete. Eg: Think about
some long cases like DKA or Hypokalemia/ adrenal mass. Your goal in DKA
is to close the “anion gap” and to monitor if your treatment is working, you
need to advance the clock quickly to receive the follow up BMP results.
Otherwise, you will run out of your “20” minutes active time.
You cannot do certain steps on 5-Minute screen
you
you
you
you
you
cannot change patient location
cannot advance the clock
cannot discharge the patient
cannot obtain results
cannot assess the patient later
You can do certain important steps on 5 Minute screen
Add any needed orders
Discontinue any unnecessary orders ( Please check the “simulated” time
before you discontinue any crucial orders. You do not want to discontinue
any stabilizing orders on day 1 or if your patient has just arrived)
You can order all “Counseling” orders “at once”. Choose the timing as
“Now” – “non invasive” steps like “counseling” do not bring your score
down. If anything, you might get credited for some counseling orders.
Use the “Later” option to your maximum advantage
Schedule “Screening” tests for a “Later” date
“Simulated” Time
The time that is scored
It is the time since the patient arrived in the “ER” or the time since
you first saw your patient in the “office” on a CCS case
In the ER cases, keep the simulated time low i.e; try to complete the
“Life saving” steps or important diagnostic tests in the least
simulated time possible. This is highly scored.
Simulated time will change only when :
You advance the clock
Do a physical
Do a “Interval” history
If you order the tests and wait, nothing will show up. Simulated time
will not change but your real time will run.
Advance the clock to make things happen. However, check the
“report” time of your orders on the order sheet, know what you are
waiting for and then advance the clock to that “particular” report
time.
Sometimes, you can advance the clock in a way that can make you look
very efficient. Move the “Simulated time” to the “Report” time that you are
waiting for by “completing a previously unfinished physical” or by “Interval/
follow up” history. Interval history will advance the clock by 2 minutes.
ER Setting
Vitals first
This is the screen where you make up your mind regarding the
“UNSTABLE” scenario. Define Shock or Respiratory failure.
Tachycardia per se, is not usually an unstable vital unless it is
associated with irregular rhythm ( you will know on physical) or
Shock.
A high temperature should remind you of the possibility of “Sepsis”,
“Infection” or “Heat Stroke”. Remember that some non-infectious
conditions like “Drug fever”, “Malignancy” or “Pulmonary embolism”
can also have fever. A high temperature may not always be
“INFECTION” ( know the definition of “SIRS” and “Sepsis”). A high
temperature is not usually an “UNSTABLE” vital unless there is a
suspicion of “Heat stroke”
Pertinent physical exam
Do not waste time doing complete physical
Fast treatment – first stabilize. After stabilizing, you can
proceed with complete physical ( do not forget it!)
Shock
Shock – defined as SBP < 90 or MAP < 65
Different types of Shock
Hypovolemic shock
Distributive shock
Septic Shock
Anaphylactic Shock
Opiod Overdose
Cardiogenic Shock
Right Ventricular MI
Left Ventricular MI
Cardiac tamponade
VSD/ Papilalry muscle rupture – post MI
Obstructive Shock
Tension Pneumothorax
Pulmonary Embolism
Air Embolism
Cardiac Tamponade
Initial Step in Shock
Suspected cause
of Shock
History clues
Physical clues
Initial therapy
Hypovolemia
-MVA with bleeding
-Orthostatic hypotension
-Dehydration
-( you have to order this
-Diarrhea
on the screen)
-Dry oral mucosa
-Tachycardia
-Stool guaic positive
-Gross bleeding
-Abdominal signs suggesting
bleeding or perforation or
peritonitis
-Heavy Vaginal bleeding
IV Fluid – NS boluses
If suspecting hemorrhagic
shock – order Type and cross
match and blood transfusion
right away ( Don’t wait for CBC)
-Vomiting
-Vaginal bleeding
Remember, Strong clues from history & vitals reveal “Shock” 
Proceed to order sheet
No clues from history  do 2 minute physical, to evaluate the
cause of shock ( add abdomen to focused physical if history
suggestive) – doing 2 minute physical will determine your next
life saving step here
Distributive
shock
- Clues to anaphylaxis
-Clues to infection ( fever on “vitals” screen)
-Clues to drug use
-Fever may point to septic shock
-Always, IV Normal saline Stat (
-Wheals - anaphylaxis
fill up the SVR)
- Epinephrine if anaphylaxis
-Antibiotics if Sespsis
Obstructive
Shock
- Chest pain/ sob – can indicate tension pneumothorax, cardiac
tamponade or PE – history clues are not very suggestive 
proceed to 2 minute physical
2 minute physical ( RS, CVS)
-Reveals absent breath sounds
Tension pneumothorax
-Reveals pulsus paradoxus, JVD
– Cardiac tamponade
-Reveals normal physical +
-historical clues  suspect PE
After 2 minute
Physical, order life saving step
Pneumo – chest tube
Tamponade pericardiocentesis
& then window
PE – Spiral ct and then tpa,
hold heparin
Air – trendelenberg position
Cardiogenic
shock
Chestpain, sob
2 minute physical – make sure
chest is clear. If rales  Left
ventricular MI. Then get EKG
If chest clear  IV Fluids. If
rales  hold IV fluids, GET
EKG, then IABC and cardiac
cath. Order other MI
management
Respiratory Failure
Respiratory Rate > 30 – unstable, tachypnea
Address it STAT
If you have a clue, go straight to order sheet ( hx of Asthma, COPD,
PE clues)
If no clues from history or associated with chest pain  do 2 minute
physical ( R.S, CVS) eg : D/D includes Tension pneumothorax,
pulmonary edema, MI with pulmonary edema, PE. By doing a 2
minute exam, you can order the “stabilizing and life saving step”
within 2 minutes of “Simulated” time . At 2 minutes of simulated time:
Chest tube if pneumothorax ( don not wait for CXR)
Pericardiocentesis if cardiac tamponade
CT chest and tpA if highly suspected PE
Morphine and furosemide if Acute Pulmonary Edema
Nebulizations ( Albuterol + Ipratropium) and corticosteroids if
asthma/ COPD exacerbation ( wide spread wheezes, accessory
muscle use)
Get ABGs in all cases of respiratory failure ( other place
where ABGs are needed is when you see low metabolic
abnormalities on BMP – you need to know Ph here)
Sepsis
Know the definition of “SIRS” – “Systemic Inflammatory Response
Syndrome”. “SIRS” is indicated by at least two of the following:
Fever or hypothermia—temperature 38°C or higher or 36°C or lower
Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”)
Tachycardia > 100 beats/ min
White blood cell count – leucocytosis (12,000 cells/mm3 or more) or
leucopenia ( 4,000 cells/mm3 or less, or greater than 10% bands on
differential count)
“SIRS” is not always due to infection. “SIRS” can be due to :
Infection
Burns
Pancreatitis
Trauma
Pulmonary embolism
Vasculitis
Sepsis : To diagnose “Sepsis”, there should be a “presumed” or
“known” site of infection + evidence of a systemic inflammatory
response ( SIRS)
Sepsis
Sepsis : To diagnose “Sepsis”, there should be a “presumed” or “known” site of infection +
evidence of a systemic inflammatory response ( SIRS)
A presumed or known site of infection is indicated by one of the following:
Purulent sputum or endotracheal secretions ( finding from history)
Physical exam with neck stiffness, altered mental status or no other source of
sepsis – suspect “meningitis”
chest x-ray with new infiltrates that can not be explained by a noninfectious
process
Radiographic or physical examination evidence of an infected collection ( CT
showing “abscess” or “physical” revealing reduced breath sounds or an
“abdominal” mass or “abscess” or “joint” swelling)
Presence of leucocytes in a normally sterile body fluid ( Ascites with > 250
neutrophils is SBP)
Positive blood cultures
Suspicion of Clostridium difficle from previous use of antibiotics in the past 3
months pr recent hospitalization or previous history of C.difficle
Urinalysis showing positive leuco-esterase or nitrite and WBCs especially, when
associated with urinary symptoms
When you have “SIRS” and you “Presume” that there might be infection  please DO NOT WAIT!
Start presumptive therapy with antibiotics ( but you should have a rationale regarding the
“presumed” source. Example: Patient has “SIRS” and urine leucoesterase is positive, no other
source identified immediately  it is absolutely fine to presume that Sepsis is possible and the
“presumed” source is “UTI” – so, please get cultures ( blood and urine) and start antibiotics right
away pending cultures. ( do not wait for cultures to come back to start antibiotics)
Septic Shock
Suspicion or evidence of sepsis + Shock
Follow quick sepsis guidelines
ABC
Oxygen
Continuos B.P monitoring
Pan cultures
IV FLUIDS – NS – MOST IMPORTANT
If BP does not improve, add a pressor. If your patient is
tachycardic, choose Nor-epinephrine. If your patient has a
low output state, use Dopamine.
Early antibiotics to address the “presumed” source
Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case
“Presumed” or “Known” site of
infection
Possible “Bugs”
Emperical therapy
Community acquired pneumonia
S.pneumoniae, Legionella, mycoplasma,
H.influenzae
Third generation cephalosporin +
macrolide or Newer Quinolone
Early Hospital Acquired Pneumonia ( < 5
days)
Gram negative rods – non resistant (
e.coli, proteus, klebsiella), S.pneumonia,
H.influenzae, legionella
PIP/TAZO, Unasyn, Cefepime or newer
quinolone
Late Hospital Acquired Pneumonia ( >
5days)
Resistant gram –ves (ESBL),
Pseudomonas, MRSA
Use anti-pseudomonal drugs –
PIP/TAZO + quinolone, Cefepime,
Imipenem, Vancomycin (if MRSA
suspected)
Intra abdominal infections ( diverticulitis)
Enteric gram –ve rods ( E.coli), Anerobes
(B.fragilis)
Use good anerobic coverage :
Cipro+flagyl, Pip/tazo, Ertapenem,
Imipenem. Do not use cephalosporin
alone ( add metronidazole if using it)
Urinary tract infections
E.coli, proteus
Enterococci
Quinolone, ceftriaxone, extended
spectrum beta lactums, if enterococci is
present  use ampicillin or vancomycin
Meningitis
S.pneumonia, H.influenzae,
N.meningitidis, E.coli. In ages < 1month
or > 50 years -Listeria
Vanco+Ceftriaxone. If listeria suspected,
add Ampicillin. Give Dexametasone prior
to antibiotics
Pseudomembranous colitis/ C.Difficle
Diarrhea
c.difficle
Metronidazole p.o. If resistant, use vanco
p.o ( do not use I.V vanco – not effective)
ER Setting – A simple approach
Presenting Issue
Next Step on CCS
Vitals” are very unstable + you, absolutely, have no clue
about the diagnosis from the history
Go to “physical screen “ – do a very focused physical ( 2
minutes – Chest and Cardiovascular. Consider “abdomen”
only if history revealed abdominal pain or trauma) 
Proceed to order sheet (Remember that when you have
no clue from the history, a “Life” saving step for a
severely unstable vital may not be identified until you do
the “2-Minute” ( Chest, Cardiovascular) physical).
Remember that if this step is done early ( less “Simulated”
time), you will get maximum score
“Vitals” are “UNSTABLE” ( Shock or respiratory failure) +
you have a clue about the diagnosis from the history
Proceed to “Order sheet” and try to stabilize. Write
“Stabilizing” orders, “Basic” orders, “Symptom” relieving
orders. Write “Specific” diagnostic tests and “Specific”
treatment since you already have a clue about the
diagnosis from the history ( Some examples: Anaphylactic
shock, Hypovolemic shock from MVA , strong clues of
“PE” in the history )
“Vitals” are “Stable” no “ Pain”
Full physical and then go to “order” sheet
“ “Vitals” stable but History reveals severe “pain”
Address pain first and then come back to physical screen
( except in abdominal pain – do abdomen exam first and
then address pain)
ER setting
In most ER cases, you can proceed to the order
sheet to stabilize your patient or to treat the
severe symptoms. But sometimes you do not
have a clue about the diagnosis and your patient
may be crashing  in such cases, do a 2 minute
physical exam to formulate your differential
diagnosis for shock or respiratory failure ( A
focused exam of CVS and RS may give you a
great clue regarding the diagnosis and at 2
minutes, you will be able to offere a definitive
treatment for your patient!)
Pain
Addressing severe pain is extremely important.
If your patient is in severe pain and vitals are
stable, go to order sheet, give a pain medication
first and then come back to physical ( except in
abdominal pain where pain medication may
mask abdominal exam signs).
Most ER pains, can use Morphine if severe
Pain in office  follow “analgesic ladder”
ER Setting
Admission if required – move patient to
ward or ICU
Criteria for admission to the ICU – shock,
resp failure, DKA, Acute MI, Refractory
electrolyte issues, Acute delirium
General Approach
Stabilization orders
Basic Tests
Symptomatic treatment ( address signs
also)
Specific diagnostic tests ( if you have a
clue from the history. If not please do
focused physical before ordering diseasespecific tests)
Specific Treatment ( if you are pretty sure)
Basic set of ER orders
Vitals
Oxy ( pulse ox, oxygen)
IVA ( IV Access)
EKG
Cardiac monitor
Urinalysis
BMP ( CMP takes 2 hours, BMP 30 mins. If you need
LFTs order them seperately)
CBC
Checking interval hx often
Don’t enter blood cx and antibiotics together. Blood cx
first, advance clock by 1 min and then antibiotics
Indications for ICU admission
Shock
Respiratory failure
Post –op 24 hours
Post MI
DKA/ Refractory electrolyte abnormalities
Acute delirium/ altered mental status
General ICU Orders
Elevate head end of the bed ( to prevent
aspiration pneumonia in ICU setting)
DVT Prophylaxis ( order compression stockings
or TED stockings)
Stress ulcer prophylaxis ( orders PPI such as
pantoprazole)
Activity ( Bed rest, ambulate in room)
Output monitoring ( Foley if obstruction or if
unresponsive/ delirium)
Diet ( NPO, Diet or NG Tube if disoriented)
Time required and Invasiveness –
tests in ER
You need have an idea about how long it takes for
certain tests and invasiveness of certain diagnostic tests
Checking report time by putting in certain orders gives
you an idea how long it takes for the test results to come
back
V/Q scan vs. CT angiogram in Unstable PE
BMP vs. CMP in DKA
CT chest vs. TEE in aortic dissection ( both take same
time. Though TEE is more specific, CT scan is least
invasive)
ABI with arterial doppler vs. Angiogram for PAD
Unresponsiveness in ER
Get basic stuff quick :
- CHECK VITALS FIRST
- ABCs – suction airway
- Do not intubate right away with out knowing the possible cause of coma
( for example, if finger stick shows low glucose – patient might respond
right away by giving dextrose)
- fingerstick glucose stat,
- naloxone given if opiates are suspected (Pupils)
- thiamine added to IV fluids if alcoholic.
Not all comatose patients need this cocktail. Check the
history – you may find clues ( heat stroke, fever with
delirium, motor weakness with delirium)
Obtaining Consults
Whether in ER setting or office setting there are some
issues where you must get consults
certain procedures – surgeries, tube thoracostomy, thoracotomy,
depression, suicide attempt, drug overdose, cardiac catheterization,
ptca, ST elevation MI, Orthopaedic procedures, eye procedures, ENT
stuff, EGD, Colonoscopy – get appropriate consults
for expert opinion
You will be credited for asking necessary consults
You can type “Obtain consent for procedure” to get
consent.
If you are obtaining a surgical consult, get the consult first
. Then, advance the clock to the “report” time of consult. If
the patient is accepted for procedure now order :
NPO
Type and crossmatch
Name of the procedure itself ( eg: hysterectomy, adrenalectomy
e.t.c)
Using keywords
Oxy
Cou
Stop
Avoid
Diet
Fluids
Advise
Vacci etc
Advancing clock
Advance only after putting appropriate
orders
If you don’t advance you will use up your
real time without nothing happening with
the patient
If you don’t advance means you have not
done the orders you wrote
Advance clock to get results when needed
Before advancing clock!
Think twice is there anything else that needs to
be done, Esply true for ER Cases
If you did not do complete physical earlier, this is
the time to do it – while awaiting the lab results,
imaging studies etc – do not advance the clock
just to get results unless you have nothing else
left to do.
Eg: you order a CBC – Let us say order time is
8:40 and report time is 9:20 – do an interval hx
or a previously unfinished physical in the mean
time that will automatically advance the clock
further.
Using control button
You can select multiple orders by using
control button so that u don’t waste much
time
Diet orders
Order appropriate diet for admissions
Type “diet” to select what u need in your
case
Follow up & Interval Hx
It does not hurt to ask a pt “how are you?”
intermittently. Do not advance the clock if u need
to put some other orders at the same time.
Obtain interval hx/follow up in pts with distress.
They might give you some valuable feedback
that may change your treatment strategy
Drug side effects – Order panels during follow
up visits – liver panel, lipid panel etc to follow up
your drug side effects as well as the efficacy.
Ordering follow up tests at a later date works
only on the 5 min screen
Follow up appointments
Schedule follow up appointments for office
visits where required and then advance
clock to get them back in ur office.
Take f/u hx each time u visit an inpatient or
during OP follow up
Counseling
Needed in all office visits
Usually done on 5-minute screen
Counsel on appropriate stuff
- Weight loss, exercise, diet, smoking & alcohol cessation
- Driving with seatbelt
- Safe sexual practices
- Asthma care
Avoid stat counseling unless extremely needed. Like in
panic attack / nervous pt
Type “counsel” press control and then select what u need
at the end of the case
Appropriate screening for office
visits
Age specific screening
You will be credited for this
If the patient came with an acute problem,
address the acute problem and diagnostic
work-up on the active screen. You can
always do Screening on the 5-minute
screen.
Invasiveness of investigations
You will not get penalized for ordering an
unnecessary non invasive investigation.
However, sometimes what seemed initially
unnecessary might give you useful information (
LFTs, Chem7)
Do not order EGDs, Intubation, Colonoscopies,
ERCPs, Chest tubes, CT with contrast if they are
not very much needed – they are invasive and
could be harmful.
For most invasive investigations you need
consults ( cardiac cath, colonoscopy, EGD,
ERCP)
Indications for admission in an
office visit
Look at vitals in office visit. A severe symptomatology may require stat
orders – cbc, chem., cardiac enz, ekg, iv access – if something unstable
or serious or if indications of admission are present as per labs/ vitals or
inability to take PO meds – send pt to ER and then admit. After entering
ER, address initial problem and then only transfer to floor/ICU
Indications for admission in office – pneumonia case ( CURB 65 –
CONFUSION, UREMIA, RR>30, SBP<90, AGE>65)
Indications for admission in office – Pyelonephritis/ PID case
Obtaining consults for office visits i.e; colonoscopy( anemia, weightloss,
constipation), EGD(weightloss, heartburn, anemia, Dysphagia,
persistent vomiting, age) , bronchoscopy (lung mass), cystoscopy
(hematuria) etc – order consult as routine, see the report time of consult
procedure and then schedule follow up visit after the consult report is
obtained.
Sending Patient home from Office
Do not keep patient waiting in the office. Address
their current symptoms, hit move pt button,
schedule a follow up visit, usually in a week (pay
attention to result report time while scheduling
follow ups) You do not want pt to come to
your clinic for follow up even before you got the
test result. – you can always call her back if
something dangerous comes out on labs even
prior to the next follow up visit. – hit the move
patient icon.
Moving the Patient
Can not use “ transfer to icu” order on the
5 min screen
Moving the pt home while awaiting orders
on Clinic case – after addressing only the
current symptoms
Schedule follow up office visit
Order follow up labs for pts on certain
drugs eg: lipid Panel, lfts etc
5-minute screen
You cant change location or obtain results
If you dint have time to put your essential Rx orders and the
case ended , put them now
D/c unnecessary orders at this time
Add d/c home medications
If pt is ready to go home, switch IV meds to oral
Do counseling
Is your patient eating?- if not already put , enter diet orders.
VERY IMP ( you can do this only on 5 min screen)  enter
follow-up tests at a later date i.e; following drug toxic effects
(LFTs, cbc etc), following the drug efficacy (lipid panel, INR
monitoring etc), following disease activity ( follow up TSH
etc)
 Enter elective screening tests for a LATER date in
an inpatient i.e; colonoscopy, pap smear, mammogram
Enter age appropriate and disease appropriate vaccines if
not entered before
Use control button – save time
Arthrocentesis orders
Fluid analysis orders
Counseling orders on the 5 min screen
Cases ending before time
Why do many cases end quickly? – how
will I know if I did well if case ended
quickly ?
 that’s the reason why you check interval
hx and vitals often
Checklist
Imaging & EKG
EKG, EEG, Echo, Ultrasound, Carotid Doppler
CXR, X ray Joints, acute abdominal series
CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.
Nursing orders
NPO, Diet, IV Fluids, Vitals, Input/output, Physical
therapy
Tubes- NG, Foley
Pulse oximetry & Oxygen, cardiac monitor
Medication orders
Counseling
Weight loss, exercise, diet, smoking & alcohol
cessation.
Checklist
Labs:
CBC, CMP, Urine routine, TSH, Lipid Profile,
Cardiac enzymes, ABG, Glucometer check,
Drug levels, Toxicology screen-Urine and
serum, ANA, ESR.
–
–
–
Bleeding & pre-op pts– Type Blood and cross
match, PT/INR, PTT.
Infections – cultures of Blood, Urine, Sputum or
CSF, as appropriate.
Acute abdomen – order amylase, lipase, b HCG &
acute abdominal X ray series.
Dyspepsia
- If warning signs or age > 50,
please do EGD
-If doing EGD, add biopsy, gastric
mucosa – H.pylori stain.
Diarrhea
Make an attempt to calssify
Infalmmatory vs. Non inflammtaory.
If inflammatory, is it bacterial or non –bacterial?
Get stool wbc, occult blood and bacterial cultures as
main work up in acute diarrhea work up
Acute MI
EKG will decide further Mx
EKG will take 15 mins
Thrombolytics vs. cardiac Cath
What if similar to dissection? Think of your
“Triad”
Pericarditis – the EKG differences. Look
“reciprocal depressions” are not seen in
pericarditis
Stroke
TIA – Thrombotic vs.Embolic
CT head with out contrast
ASA vs. Aggrenox
EKG, 2D Echo to r/o cardiac origin
Carotid doppler to r/o carotid stenosis
If carotid stenosis and meets criteria ?  CEA
Shock
Respiratory Failure
Polymyalgia Rheumatica
Exclude other differential diagnosis
Get an ESR. ESR > 100 very suggestive of polymyalgia in
presence of typical clinical features
Temporal aretery biopsy if suggesting associated temporal arteritis.
Get baseline DEXA if starting steroids
Prevent osteoprorosis if starting steroids
HUS
Diarrhea preceding Presentation
R/o other causes of microangiopathic hemolysis
Demonstrate schistocytes on peripheral smear
Supportive theray as initial choice
Monitor CBC and BMP
If Clinical picture worsens, get plasmapheresis
If BMP worsens, get HD
Delirium in Elderly
Sun downing
Dementia
Sepsis : UTI, Pneumonia and
C.difficle
Secondary Hypertension
Hyperaldosteronism
Hypokalemia with leg cramps
Get hormonal tests ( PAC/ PRA) prior to CT imaging
Spironolactone as medical therapy
CT may show adrenal adenoma
Call surgical consult
If accepted, order adrenalectomy