Archer USMLE Step 3 CCS workshop 2015

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Updated Archer USMLE Step 3 CCS Workshop sample slides reflecting new USMLE Step 3 CCS changes. Archer CCS Workshops will be organized every month and will demonstrate several highyield strategies to subscribers. Subscribers will also be involved in interactive practice of CCS cases during the live CCS webinar . Interact, participate, discuss and practice cases under supervision of expert teaching physicians without having to leave your home via. Archer Interactive live webinars. For those who can not attend live webinars and those that are more comfortable in reviewing CCS at their own convenience, Pay-per-view of our recorded CCS live webinars are available at http://www.ccsworkshop.com

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Archer USMLE Step 3 CCS workshop 2015

  1. 1. Archer USMLE Step 3 CCS Workshop A component of Archer Online USMLE Reviews WWW.CCSWORKSHOP.COM USMLE Galaxy, LLC All Rights reserved. “ Dr.Red CCS Workshop” and “Archer CCS Workshop” are trademarks owned by USMLE Galaxy, LLC All slides are copyrighted. Monitored by DMCA.
  2. 2. Webinar – Muting/ Unmuting <ul><li>WELCOME! We will begin as soon as all the attendees arrive! Thank you! </li></ul><ul><li>Some times there is an echo/ noise that gets transmitted in to webinar from the attendee’s surroundings. If you are using a computer microphone, there should be a mute option for you. If there is an echo from your side, you can mute yourself and un-mute when you wish to talk. </li></ul><ul><li>If there still is a noise, we will keep you muted. In that case, if you have Questions, please raise your hand so that you will be un-muted as soon as possible and your questions will be answered </li></ul>
  3. 3. New Changes To CCS -2012 <ul><li>New changes will appear on CCS component of Step 3 starting Mid-February 2012. The transition will be complete by Mid-March 2012. Examinees taking the test between 2/14/2012 and 3/15/2012 may encounter either version on the exam. Examinees taking after March 15 th 2012, will only get the new version . </li></ul><ul><li>Changes may mean even more increased importance to CCS in scoring ( this is our opinion). USMLE probably intends to have more case scenarios in order to increase the importance of CCS. </li></ul>
  4. 4. New Changes To CCS -2012 <ul><li>Changes are with regard to “REAL” time and number of cases only. Simulation time, case approaches, software navigation, locations and CCS strategies to score high will remain the same. </li></ul><ul><li>Prior to Mid-Feb 2012, examinees are given 9 CCS cases with 25 minutes REAL time. </li></ul><ul><li>From Mid-Feb’2012; there will be 12 CCS cases as follows: </li></ul><ul><ul><ul><li>8 cases with “Real” time of 20 minutes each. </li></ul></ul></ul><ul><ul><ul><li>4 cases with “Real” time of 10 minutes each. </li></ul></ul></ul><ul><li>The “case-end” screen which used have 5 minutes “REAL” time will now have only “2 Minutes” Real time. This will now be called as “ 2 minute screen” in our workshops instead of referring it as “5 minute “ screen . </li></ul><ul><li>As discussed in “Archer CCS strategies”, all important guidelines to be implemented on case-end screen previously referred to as “5-Min screen orders” must now be done on 2-min screen. </li></ul>
  5. 5. CCS Tips <ul><li>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. </li></ul><ul><li>In the setting of ER, do not waste time if vitals are unstable. Don not discharge the patient without confirmed diagnosis or with-out stabilizing him. 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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  6. 6. CCS Tips <ul><li>Two “Times” on the software </li></ul><ul><ul><ul><li>“ Real” time – the time on the bottom of the screen on the right side. </li></ul></ul></ul><ul><ul><ul><li>“ Simulated” time – the time on the bottom of the screen on the left side </li></ul></ul></ul>
  7. 7. New Changes To CCS -2012 <ul><li>REAL TIMES: </li></ul><ul><li>20 minute cases : </li></ul><ul><ul><ul><li>18 minutes for “active” screen and 2 minutes for “Case-end” screen. </li></ul></ul></ul><ul><li>10 minute cases : </li></ul><ul><ul><ul><li>8 minutes for “active” screen and 2 minutes for </li></ul></ul></ul><ul><ul><ul><li>“ Case-end” screen. </li></ul></ul></ul><ul><li>New changes mean less “real” time for you to complete the case. You need to be fast in navigating the software and you need to prioritize your orders! You need lot more practice with the software to thoroughly orient yourself ! </li></ul><ul><li>New changes do not change anything else! No change in scoring parameters or software navigation or appearance </li></ul>
  8. 8. “ Real ” Time <ul><li>“ Real” time – the time on the bottom of the screen on the right side. </li></ul><ul><ul><ul><li>You have “18” minutes or “8” minutes to complete the cases . “8” of your cases will have 18 minutes real time and 4 of your cases will have 8 minutes real time. </li></ul></ul></ul><ul><ul><ul><li>Real time is not scored. However, if you run out of the real time of - your “2” minute screen will pop up. Since you cannot do certain important steps on 2-minute screen, make sure you set your goals on your case and reach them before the “Real” time expires. 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 “18” minutes active “real” time and will not be able to optimally complete the case. </li></ul></ul></ul>
  9. 9. Case end (2-minute screen) <ul><li>You cannot do certain steps on 2-Minute screen </li></ul><ul><ul><ul><ul><ul><li>you cannot change patient location </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>you cannot advance the clock </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>you cannot discharge the patient </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>you cannot obtain results </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>you cannot assess the patient later </li></ul></ul></ul></ul></ul><ul><li>You can do certain important steps on 2 Minute screen. </li></ul><ul><ul><ul><li>Prioritize your 2-minute screen orders in the following order. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Add any needed orders to be done “NOW” </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Discontinue any unnecessary orders that are appropriate “NOW”. Understand the meaning of word “NOW”. The word “NOW” refers to that “simulated time” at that point in patient’s life. ( 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). </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Add any tests or orders or follow-up monitoring relevant to the patient’s current presentation to be done in “ LATER ” . “LATER” refers to future simulated time which you can select using the calendar. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>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. However, prioritize these counseling orders . You only have two minutes – if you are running out of time, do not bother to do “routine” counselling . As long as you ordered “case-specific” counseling , you are good! </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Schedule “Screening” tests for a “Later” date </li></ul></ul></ul></ul></ul>
  10. 10. “ Simulated” Time <ul><li>The time that is scored </li></ul><ul><li>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. </li></ul><ul><li>This is the time that is most crucial in ER cases. For most unstable cases, you are expected to complete life-saving steps or therapies within first 1 hour of SIMULATED time. </li></ul><ul><li>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 . </li></ul><ul><li>Simulated time will change only when : </li></ul><ul><ul><ul><li>You advance the clock </li></ul></ul></ul><ul><ul><ul><li>Do a physical </li></ul></ul></ul><ul><ul><ul><li>Do a “Interval” history </li></ul></ul></ul><ul><li>If you order the tests and wait, nothing will show up. Simulated time will not change but your real time will run. </li></ul><ul><li>Advance the clock to make things happen. However, check the “report” time of your orders on the order sheet, know your goals, know your monitoring parameters and what you are waiting for and then advance the clock to that “particular” report time. </li></ul><ul><ul><ul><li>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. </li></ul></ul></ul>
  11. 11. Areas that are scored <ul><li>Several of your approaches may be scored . Your approaches will be scored as “optimal”, “sub-optimal” or “poor”. If have satisfied most of the “optimal” steps and did not involve in any “unnecessary invasive or harmful” steps, you will receive > 90% of the Score. </li></ul>
  12. 12. Areas that are scored <ul><li>Most important areas that are scored: </li></ul><ul><ul><ul><li>Diagnosis ( history and physical exam, appropriate diagnostic tests. “Focused” physical only when patients are unstable) </li></ul></ul></ul><ul><ul><ul><li>Location ( Location of your treatment and evaluation. Unstable cases should be sent to ER as soon as possible after initial therapy in office. Doing tests in office takes longer than doing tests in ER. Once ER cases are stabilized and preliminary diagnosis is obtained, “CHANGE LOCATION”. If ICU criteria are met, send to ICU. If not met, send to ward. ) </li></ul></ul></ul><ul><ul><ul><li>Timing ( Keeping the “Simulated” time low in ER cases or unstable cases i.e; ordering “optimal” steps within usually, first “one hour” of patient simulated time) </li></ul></ul></ul><ul><ul><ul><li>Sequencing ( Sequencing your orders . For example, stabilizing a patient first and then ordering an imaging study in aortic dissection before obtaining a surgery consult. This is just an example! Sequencing will be demonstrated more in our practice cases. Correct “Sequencing” is extremely important ) </li></ul></ul></ul><ul><ul><ul><li>Monitoring ( Once you treat a patient, MONITOR!! That’s your JOB !. Monitoring parameters can be as simple as doing a repeat focused physical or labs( chest exam in “Asthma” cases after treatment, repeat vitals in shock, respiratory failure cases, repeat neuro-checks in coma/delirium cases , repeat BMP in DKA cases ) to as complex as obtaining “later” tests to monitor drug adverse effects or drug efficiency in some office cases …For example: getting a “lipid panel” and “LFT” s at an appropriate later date after starting STATINS in an office case. Another example is getting “LFTs” at a later date after starting Methotrexate in a Rheumatoid arthritis case ( 30days after initiation) ) – Follow MONITORING GUIDELINES </li></ul></ul></ul>
  13. 13. ER Setting <ul><li>Vitals first </li></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>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” </li></ul></ul></ul><ul><li>Pertinent physical exam </li></ul><ul><li>Do not waste time doing complete physical. ( Doing complete physical is regarded as “poor management” in unstable cases) </li></ul><ul><li>Fast treatment – first stabilize. After stabilizing and after treating adequately , you can proceed with complete physical ( do not forget it!) </li></ul>
  14. 14. Shock <ul><li>Shock – defined as SBP < 90 or MAP < 65 </li></ul><ul><li>Different types of Shock </li></ul><ul><ul><ul><li>Hypovolemic shock </li></ul></ul></ul><ul><ul><ul><li>Distributive shock </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Septic Shock </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Anaphylactic Shock </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Opiod Overdose </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Cardiogenic Shock </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Right Ventricular MI </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Left Ventricular MI </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cardiac tamponade </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>VSD/ Papilalry muscle rupture – post MI </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Obstructive Shock </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Tension Pneumothorax </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pulmonary Embolism </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Air Embolism </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cardiac Tamponade </li></ul></ul></ul></ul></ul>
  15. 15. Initial Step in Shock Suspected cause of Shock History clues Physical clues Initial therapy Hypovolemia <ul><li>MVA with bleeding </li></ul><ul><li>Dehydration </li></ul><ul><li>Diarrhea </li></ul><ul><li>Vomiting </li></ul><ul><li>Vaginal bleeding </li></ul><ul><li>Remember, Strong clues from history & vitals reveal “Shock”  Proceed to order sheet </li></ul><ul><li>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 </li></ul><ul><li>Orthostatic hypotension </li></ul><ul><li>( you have to order this </li></ul><ul><li>on the screen) </li></ul><ul><li>Dry oral mucosa </li></ul><ul><li>Tachycardia </li></ul><ul><li>Stool guaic positive </li></ul><ul><li>Gross bleeding </li></ul><ul><li>Abdominal signs suggesting </li></ul><ul><li>bleeding or perforation or peritonitis </li></ul><ul><li>Heavy Vaginal bleeding </li></ul>IV Fluid – NS boluses If suspecting hemorrhagic shock – order Type and cross match and blood transfusion right away ( Don’t wait for CBC) Distributive shock <ul><li>- Clues to anaphylaxis </li></ul><ul><li>Clues to infection ( fever on “vitals” screen) </li></ul><ul><li>Clues to drug use </li></ul><ul><li>Fever may point to septic shock </li></ul><ul><li>Wheals - anaphylaxis </li></ul><ul><li>Always, IV Normal saline Stat ( fill up the SVR) </li></ul><ul><li>Epinephrine if anaphylaxis </li></ul><ul><li>Antibiotics if Sespsis </li></ul>Obstructive Shock - Chest pain/ sob – can indicate tension pneumothorax, cardiac tamponade or PE – history clues are not very suggestive  proceed to 2 minute physical <ul><li>2 minute physical ( RS, CVS) </li></ul><ul><li>Reveals absent breath sounds </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Reveals pulsus paradoxus, JVD </li></ul><ul><li>– Cardiac tamponade </li></ul><ul><li>Reveals normal physical + </li></ul><ul><li>historical clues  suspect PE </li></ul>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
  16. 16. Respiratory Failure <ul><li>Respiratory Rate > 30 – unstable, tachypnea </li></ul><ul><li>Address it STAT </li></ul><ul><li>If you have a clue, go straight to order sheet ( hx of Asthma, COPD, PE clues) </li></ul><ul><li>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: </li></ul><ul><ul><ul><li>Chest tube if pneumothorax ( don not wait for CXR) </li></ul></ul></ul><ul><ul><ul><li>Pericardiocentesis if cardiac tamponade </li></ul></ul></ul><ul><ul><ul><li>CT chest and tpA if highly suspected PE </li></ul></ul></ul><ul><ul><ul><li>Morphine and furosemide if Acute Pulmonary Edema </li></ul></ul></ul><ul><ul><ul><li>Nebulizations ( Albuterol + Ipratropium) and corticosteroids if asthma/ COPD exacerbation ( wide spread wheezes, accessory muscle use) </li></ul></ul></ul><ul><li>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) </li></ul>
  17. 17. Sepsis <ul><li>Know the definition of “SIRS” – “Systemic Inflammatory Response Syndrome”. “SIRS” is indicated by at least two of the following: </li></ul><ul><ul><ul><ul><ul><li>Fever or hypothermia—temperature 38°C or higher or 36°C or lower </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Tachycardia > 100 beats/ min </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>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) </li></ul></ul></ul></ul></ul><ul><li>“ SIRS” is not always due to infection. “SIRS” can be due to : </li></ul><ul><ul><ul><ul><ul><li>Infection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Burns </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pancreatitis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pulmonary embolism </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vasculitis </li></ul></ul></ul></ul></ul><ul><li>Sepsis : To diagnose “Sepsis”, there should be a “presumed” or “known” site of infection + evidence of a systemic inflammatory response ( SIRS) </li></ul>
  18. 18. Sepsis <ul><li>Sepsis : To diagnose “Sepsis”, there should be a “presumed” or “known” site of infection + evidence of a systemic inflammatory response ( SIRS) </li></ul><ul><li>A presumed or known site of infection is indicated by one of the following: </li></ul><ul><ul><ul><li>Purulent sputum or endotracheal secretions ( finding from history) </li></ul></ul></ul><ul><ul><ul><li>Physical exam with neck stiffness, altered mental status or no other source of sepsis – suspect “meningitis” </li></ul></ul></ul><ul><ul><ul><li>chest x-ray with new infiltrates that can not be explained by a noninfectious process </li></ul></ul></ul><ul><ul><ul><li>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) </li></ul></ul></ul><ul><ul><ul><li>Presence of leucocytes in a normally sterile body fluid ( Ascites with > 250 neutrophils is SBP) </li></ul></ul></ul><ul><ul><ul><li>Positive blood cultures </li></ul></ul></ul><ul><ul><ul><li>Suspicion of Clostridium difficle from previous use of antibiotics in the past 3 months pr recent hospitalization or previous history of C.difficle </li></ul></ul></ul><ul><ul><ul><li>Urinalysis showing positive leuco-esterase or nitrite and WBCs especially, when associated with urinary symptoms </li></ul></ul></ul><ul><li>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) </li></ul>
  19. 19. Septic Shock <ul><li>Suspicion or evidence of sepsis + Shock </li></ul><ul><li>Follow quick sepsis guidelines </li></ul><ul><ul><ul><li>ABC </li></ul></ul></ul><ul><ul><ul><li>Oxygen </li></ul></ul></ul><ul><ul><ul><li>Continuos B.P monitoring </li></ul></ul></ul><ul><ul><ul><li>Pan cultures </li></ul></ul></ul><ul><ul><ul><li>IV FLUIDS – NS – MOST IMPORTANT </li></ul></ul></ul><ul><ul><ul><li>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. </li></ul></ul></ul><ul><ul><ul><li>Early antibiotics to address the “presumed” source </li></ul></ul></ul>
  20. 20. 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)
  21. 21. 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)
  22. 22. ER setting <ul><li>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!) </li></ul>
  23. 23. Pain <ul><li>Consider “Pain” as the fifth vital </li></ul><ul><li>Addressing severe pain immediately is extremely important . </li></ul><ul><li>If your patient is in severe pain and vitals are stable, go to order sheet first , give a pain medication first and then go back to do “focused” physical. </li></ul><ul><li>Most ER pains, can use Morphine if severe </li></ul><ul><li>Pain in office  follow “analgesic ladder” </li></ul>
  24. 24. ER Setting <ul><li>Admission if required – move patient to ward or ICU </li></ul><ul><li>Criteria for admission to the ICU – shock, resp failure, DKA, Acute MI, Refractory electrolyte issues, Acute delirium </li></ul>
  25. 25. General Approach <ul><li>Stabilization orders </li></ul><ul><li>Basic Tests </li></ul><ul><li>Symptomatic treatment ( address signs also) </li></ul><ul><li>Specific diagnostic tests ( if you have a clue from the history. If not please do focused physical before ordering disease-specific tests) </li></ul><ul><li>Specific Treatment ( if you are pretty sure) </li></ul>
  26. 26. Basic set of ER orders <ul><li>Vitals </li></ul><ul><li>Oxy ( pulse ox, oxygen) </li></ul><ul><li>IVA ( IV Access) </li></ul><ul><li>EKG </li></ul><ul><li>Cardiac monitor </li></ul><ul><li>Urinalysis </li></ul><ul><li>BMP ( CMP takes 2 hours, BMP 30 minutess. If you need LFTs order them separately rather than ordering a CMP) </li></ul><ul><li>CBC </li></ul><ul><li>Checking interval history often is a type of “monitoring” </li></ul><ul><li>Don’t enter blood cultures and antibiotics together. Blood cx first, advance clock by 1 min and then antibiotics. This is very important in case of Infective Endocarditis where blood cultures x 3 must be obtained 30 minutes apart before starting antibiotics – cultures here dictate management decisions further in that case </li></ul>
  27. 27. Indications for ICU admission <ul><li>Shock </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Post –op 24 hours in some cases </li></ul><ul><li>Post MI </li></ul><ul><li>DKA/ Refractory electrolyte abnormalities </li></ul><ul><li>Acute delirium/ altered mental status </li></ul>
  28. 28. General ICU Orders <ul><li>Elevate head end of the bed ( to prevent aspiration pneumonia in ICU setting) </li></ul><ul><li>DVT Prophylaxis ( order compression stockings or TED stockings) </li></ul><ul><li>Stress ulcer prophylaxis ( orders PPI such as pantoprazole) </li></ul><ul><li>Activity ( Bed rest, ambulate in room) </li></ul><ul><li>Output monitoring ( Foley if obstruction or if unresponsive/ delirium) </li></ul><ul><li>Diet ( NPO, Diet or NG Tube if disoriented) </li></ul><ul><li>Neurochecks if disoriented </li></ul><ul><li>Suction airway if comatose or disoriented </li></ul>
  29. 29. Time required and Invasiveness – tests in ER <ul><li>TIMING & INVASION </li></ul><ul><li>You need have an idea about how long it takes for certain tests and invasiveness of certain diagnostic tests </li></ul><ul><li>Checking report time by putting in certain orders gives you an idea how long it takes for the test results to come back </li></ul><ul><li>V/Q scan vs. CT angiogram in Unstable PE </li></ul><ul><li>BMP vs. CMP in DKA </li></ul><ul><li>CT chest vs. TEE in aortic dissection ( both take same time. Though TEE is more specific, CT scan is least invasive) </li></ul><ul><li>ABI with arterial doppler vs. Angiogram for PAD </li></ul>
  30. 30. Unresponsiveness in ER <ul><li>Get basic stuff quickLY : </li></ul><ul><li>CHECK VITALS FIRST </li></ul><ul><li>ABCs – suction airway </li></ul><ul><ul><ul><ul><li>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 after giving dextrose). Look and exclude rapidly reversible causes of coma by using history, physical and lab tests </li></ul></ul></ul></ul><ul><ul><ul><ul><li>( hypoglycemia, opiod overdose, BZD overdose, hepatic encephalopathy etc) before you prophylactically intubate for airway protection in coma </li></ul></ul></ul></ul><ul><li>- fingerstick glucose stat (Accucheck), </li></ul><ul><li>- naloxone given if opiates are suspected (Pupils) </li></ul><ul><li>thiamine added to IV fluids if alcoholic. </li></ul><ul><li>Not all comatose patients need this cocktail. Check the history – you may find clues ( heat stroke, fever with delirium, motor weakness with delirium, finger stick glucose very high with delirium as in DKA or HONK) </li></ul>
  31. 31. Obtaining Consults <ul><li>Whether in ER setting or office setting there are some issues where you must get consults </li></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>for expert opinion </li></ul></ul></ul><ul><li>You will be credited for asking necessary consults </li></ul><ul><li>You can type “Obtain consent for procedure” to get consent. </li></ul><ul><li>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 : </li></ul><ul><ul><ul><li>NPO </li></ul></ul></ul><ul><ul><ul><li>Obtain consent for procedure </li></ul></ul></ul><ul><ul><ul><li>IV access </li></ul></ul></ul><ul><ul><ul><li>Type and crossmatch </li></ul></ul></ul><ul><ul><ul><li>PT, PTT </li></ul></ul></ul><ul><ul><ul><li>Name of the procedure itself ( eg: hysterectomy, adrenalectomy e.t.c) </li></ul></ul></ul><ul><li>Surgeon will always accept the patient for surgery if the criteria for surgery are met. If the surgeon did not accept, check carefully if you have met the criteria. If you have not, order necessary tests to meet the criteria for surgery if surgery is indicated. If you feel surgeon is not accepting even after you have completely met the criteria, it is possible that surgery is not the treatment of choice at that time in the software algorithm  do not order surgical procedure if the patient is not accepted by the surgeon ! </li></ul>
  32. 32. Using keywords <ul><li>Oxy </li></ul><ul><li>Cou </li></ul><ul><li>Stop </li></ul><ul><li>Avoid </li></ul><ul><li>Diet </li></ul><ul><li>Fluids </li></ul><ul><li>Advise </li></ul><ul><li>Vacci etc </li></ul>
  33. 33. Advancing clock <ul><li>Advance only after putting appropriate orders </li></ul><ul><li>If you do not advance you will use up your real time without nothing happening with the patient </li></ul><ul><li>If you do not advance , it means you have not implemented the orders you wrote </li></ul><ul><li>Advance clock to get results when needed </li></ul>
  34. 34. Before advancing clock! <ul><li>Think twice is there anything else that needs to be done, Esply true for ER Cases </li></ul><ul><li>If you already stabilized the patient but had done only focused physical at presentation in ER, you may use this waiting time to complete your other relevant physical - 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. </li></ul><ul><li>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. </li></ul>
  35. 35. Stop Clock Function <ul><li>Stop the clock function is a critical step. </li></ul><ul><li>When you start advancing the clock to a future time, several results of the tests you ordered or patient updates start to pop up. Each result or patient update may give you information that is important to accurately proceed with the case. </li></ul><ul><li>When results or updates come up, they come with two options each and every time - &quot;Stop the clock&quot; or “Continue&quot;. If the result needs to be addressed immediately, stop the clock and put the immediate necessary treatment orders or diagnostic orders to address that important result. If the result is trivial or if it can be addressed at a later time, you can choose to &quot;continue&quot; the clock until you reach the time you want. </li></ul><ul><li>The following is very important and can affect your score in Office Cases: </li></ul><ul><ul><ul><li>“ Stop the clock&quot; after the result is very important in office cases scenarios as well. When the patient is at &quot;Home&quot;, the results still keep coming up before the patient's next appointment. You should look at the results and if any result needs to be addressed immediately, you must &quot;Stop the clock&quot; and put in further tests or common oral treatments on the order sheet even though patient's location is showing at &quot;HOME&quot;. If the results are dangerous ( like a potassium of 2.5 which is life threatening) and if you think that the patient needs iv treatments or admission for severe symptomatology or admission for threatening results, you must &quot;Stop the clock&quot; and change the patient location to &quot;ER&quot; and then give further iv treatments.  When critical patient “updates” or results mandate immediate attention, advancing the clock without addressing those updates would advance the simulated time and will adversely affect your score on that case. ( The software will regard this as failure to address critical findings in a timely manner which may be life threatening to the patient). </li></ul></ul></ul><ul><ul><ul><li>In office cases, when you press &quot;Stop the clock&quot; button previous appointment will be cancelled. You must reschedule the appointment after each time you stop the clock. This memory of previously scheduled appointment is lost on the software because when you stop the clock you stop it because you saw an important result and such a decision may lead you to pre-pone or post-pone the appointment. So, you must schedule the appointment again each time after you stop the clock &quot; </li></ul></ul></ul>
  36. 36. Using control button <ul><li>You can select multiple orders by using control button so that u don’t waste much time </li></ul>
  37. 37. Diet orders <ul><li>Order appropriate diet for admissions </li></ul><ul><li>Type “diet” to select what you need in your case </li></ul>
  38. 38. Follow up & Interval Hx <ul><li>It does not hurt to ask a patient “how are you?” intermittently. Do not advance the clock if you need to put some other orders at the same time. </li></ul><ul><li>Obtain interval history/follow up in patients with distress. They might give you some valuable feedback that may change your treatment strategy. Once they are stabilized and comfortable , go back and get interval history. If they did not give you full history at presentation, they will give it to you now! Obtaining this full history may sometimes, help in further treatment </li></ul><ul><li>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. </li></ul><ul><li>Ordering follow up tests at a later date works only on the 2 min screen </li></ul>
  39. 39. Follow up appointments <ul><li>Schedule follow up appointments for office visits where required and then advance clock to get them back in your office. </li></ul><ul><li>Take follow-up history each time you visit an inpatient or during out-patient follow up </li></ul>
  40. 40. Counseling <ul><li>Needed in all office visits </li></ul><ul><li>Usually done on 2-minute screen as you can choose multiple counsel options at once here using a control button. This prevents your “real time” from being wasted in the active case for these routine orders. If you have other “later” orders that are relevant to “monitoring” in that case, enter those first before entering these “routine” counseling orders so that you do not run out of your valuable time on 2 min screen . </li></ul><ul><ul><ul><li>Type “counsel” press control and then select what you need at the end of the case. </li></ul></ul></ul><ul><ul><ul><li>Routine counseling may not be scored at all after 2 min screens are introduced. </li></ul></ul></ul><ul><li>Counsel on appropriate issues </li></ul><ul><ul><ul><li>- Weight loss, exercise, diet, smoking & alcohol cessation </li></ul></ul></ul><ul><ul><ul><li>- Driving with seatbelt </li></ul></ul></ul><ul><ul><ul><li>- Safe sexual practices </li></ul></ul></ul><ul><ul><ul><li>Asthma care </li></ul></ul></ul><ul><li>Avoid stat counseling unless extremely needed. Like in panic attack / nervous patient. Some counsel orders are important at the initial visit itself – DO NOT wait until 2 min screen ( counsel, cancer diagnosis, home glucose monitoring, smoking cessation, sexual partner needs treatment, using epipen, counseling asthma care and side-effects in childhood asthma etc in appropriate case scenarios). </li></ul>
  41. 41. Appropriate screening for office visits <ul><li>Age specific screening </li></ul><ul><li>You will be credited for this </li></ul><ul><li>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 2-minute screen by scheduling them for a “later” date. </li></ul>
  42. 42. Invasiveness of investigations <ul><li>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) </li></ul><ul><li>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. </li></ul><ul><li>For most invasive investigations you need consults ( cardiac cath, colonoscopy, EGD, ERCP) </li></ul>
  43. 43. Indications for admission in an office visit <ul><li>Location </li></ul><ul><li>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 </li></ul><ul><li>Indications for admission in office – pneumonia case ( CURB 65 – CONFUSION, UREMIA, RR>30, SBP<90, AGE>65) </li></ul><ul><li>Indications for admission in office – Pyelonephritis/ PID case </li></ul><ul><li>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. </li></ul>
  44. 44. Sending Patient home from Office <ul><li>Location </li></ul><ul><li>Do not keep patient waiting in the office. Address their current symptoms, hit move patient 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. </li></ul>
  45. 45. Moving the Patient <ul><li>LOCATION </li></ul><ul><li>Can not use “ transfer to icu” order on the 2 min screen </li></ul><ul><li>Moving the patient home while awaiting orders on Clinic case – after addressing only the current symptoms </li></ul><ul><li>Schedule follow up office visit </li></ul><ul><li>Order follow up labs for pts on certain drugs eg: lipid Panel, lfts etc </li></ul>
  46. 46. 2-minute screen <ul><li>You cant change location or obtain results </li></ul><ul><li>PRIORTIZE! Prioritize! Prioritize your orders! You ONLY have 2 minutes. Important treatment and monitoring orders first and then, specific counseling if not already done and then only, routine counseling and screening! </li></ul><ul><li>If you did not have time to put your essential treatment orders and the case ended , put them now </li></ul><ul><li>Discontinue unnecessary orders at this time ( if unnecessary at that point simulated time ) </li></ul><ul><li>Add discharge home medications if patient simulated time and if patient clinical situation meets discharge criteria. </li></ul><ul><li>If patient is ready to go home, switch IV meds to oral </li></ul><ul><li>Do counseling </li></ul><ul><li>Is your patient eating?- if not already put , enter diet orders. </li></ul><ul><li>Monitoring for later date : VERY IMPORTANT ( you can do this only on 2 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) </li></ul><ul><li> Enter elective screening tests for a LATER date in an inpatient i.e; colonoscopy, pap smear, mammogram </li></ul><ul><li>Enter age appropriate and disease appropriate vaccines if not entered before </li></ul>
  47. 47. Use control button – Save “Real time <ul><li>Arthrocentesis orders </li></ul><ul><li>Fluid analysis orders </li></ul><ul><li>Counseling orders on the 2 min screen </li></ul><ul><li>Other orders like: </li></ul><ul><ul><ul><li>“ diabetic” </li></ul></ul></ul><ul><ul><ul><li>“ cardiac” </li></ul></ul></ul><ul><ul><ul><li>“ Oxy” etc </li></ul></ul></ul>
  48. 48. Do not waste time staring at the screen – Save “Real” time <ul><li>With new changes in Feb 2012, you only have “ active ” REAL times of 18 minutes and 8 minutes for long and short cases respectively . You must reach diagnostic, therapeutic and “ immediate ” monitoring goals for that case in this time. To reach these goals in certain cases, you will need to advance the clock much farther in patient “simulated” time ( For example: in DKA case, anion gap does not close for a long time). “ Later ” monitoring goals can be achieved on 2 min screen. </li></ul><ul><li>You must practice thoroughly. </li></ul><ul><li>You need to be very fast with navigation </li></ul><ul><li>Master Archer strategies and practice them several times. </li></ul><ul><li>Have a quick plan for treating and then, monitoring. Once you have a plan , YOU MUST MOVE AHEAD WITH CLOCK NAVIGATION -----start “advancing” the clock to get to your goal fast! </li></ul>
  49. 49. Cases ending before time <ul><li>Why do many cases end quickly? – how will I know if I did well if case ended quickly ? </li></ul><ul><li> That is the reason why you need to check interval history and vitals often. </li></ul><ul><li>This is the reason you need to monitor your laboratory or clinical parameters (physical, vitals) pertinent to that case </li></ul><ul><li>If monitoring parameters are improving and if case ended before allotted “real” time, it means you have done very well . </li></ul><ul><li>If monitoring parameters are deteriorating and if case ended before allotted “real” time, it means you have NOT done well. </li></ul>
  50. 50. Checklist <ul><li>Imaging & EKG </li></ul><ul><ul><li>  EKG, EEG, Echo, Ultrasound, Carotid Doppler </li></ul></ul><ul><ul><li>CXR, X ray Joints, acute abdominal series </li></ul></ul><ul><ul><li>CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.   </li></ul></ul><ul><li>Nursing orders </li></ul><ul><li>NPO, Diet, IV Fluids, Vitals, Input/output, Physical therapy </li></ul><ul><li>Tubes- NG, Foley </li></ul><ul><li>Pulse oximetry & Oxygen, cardiac monitor  </li></ul><ul><li>Medication orders  </li></ul><ul><li>Counseling </li></ul><ul><li>Weight loss, exercise, diet, smoking & alcohol cessation.  </li></ul>
  51. 51. Checklist <ul><li>Labs: </li></ul><ul><li>CBC, CMP, Urine routine, TSH, Lipid Profile, Cardiac enzymes, ABG, Glucometer check, Drug levels, Toxicology screen-Urine and serum, ANA, ESR. </li></ul><ul><ul><li>Bleeding & pre-op pts– Type Blood and cross match, PT/INR, PTT. </li></ul></ul><ul><ul><li>Infections – cultures of Blood, Urine, Sputum or CSF, as appropriate. </li></ul></ul><ul><ul><li>Acute abdomen – order amylase, lipase, b HCG & acute abdominal X ray series.  </li></ul></ul>
  52. 52. Dyspepsia <ul><li>- If warning signs or age > 50, please do EGD </li></ul><ul><li>If doing EGD, add biopsy, gastric mucosa – H.pylori stain. </li></ul>
  53. 53. Diarrhea <ul><li>Make an attempt to calssify </li></ul><ul><li>Infalmmatory vs. Non inflammtaory. </li></ul><ul><li>If inflammatory, is it bacterial or non –bacterial? </li></ul><ul><li>Get stool wbc, occult blood and bacterial cultures as main work up in acute diarrhea work up </li></ul>
  54. 54. Acute MI <ul><li>EKG will decide further Mx </li></ul><ul><li>EKG will take 15 mins </li></ul><ul><li>Thrombolytics vs. cardiac Cath </li></ul><ul><li>What if similar to dissection? Think of your “Triad” </li></ul><ul><li>Pericarditis – the EKG differences. Look “reciprocal depressions” are not seen in pericarditis </li></ul>
  55. 55. Stroke <ul><li>TIA – Thrombotic vs.Embolic </li></ul><ul><li>CT head with out contrast </li></ul><ul><li>ASA vs. Aggrenox </li></ul><ul><li>EKG, 2D Echo to r/o cardiac origin </li></ul><ul><li>Carotid doppler to r/o carotid stenosis </li></ul><ul><li>If carotid stenosis and meets criteria ?  CEA </li></ul>
  56. 56. Shock
  57. 57. Respiratory Failure
  58. 58. Polymyalgia Rheumatica <ul><li>Exclude other differential diagnosis </li></ul><ul><li>Get an ESR. ESR > 100 very suggestive of polymyalgia in presence of typical clinical features </li></ul><ul><li>Temporal aretery biopsy if suggesting associated temporal arteritis. </li></ul><ul><li>Get baseline DEXA if starting steroids </li></ul><ul><li>Prevent osteoprorosis if starting steroids </li></ul>
  59. 59. HUS <ul><li>Diarrhea preceding Presentation </li></ul><ul><li>R/o other causes of microangiopathic hemolysis </li></ul><ul><li>Demonstrate schistocytes on peripheral smear </li></ul><ul><li>Supportive theray as initial choice </li></ul><ul><li>Monitor CBC and BMP </li></ul><ul><li>If Clinical picture worsens, get plasmapheresis </li></ul><ul><li>If BMP worsens, get HD </li></ul>
  60. 60. Delirium in Elderly <ul><li>Sun downing </li></ul><ul><li>Dementia </li></ul><ul><li>Sepsis : UTI, Pneumonia and C.difficle </li></ul>
  61. 61. Secondary Hypertension Hyperaldosteronism <ul><li>Hypokalemia with leg cramps </li></ul><ul><li>Get hormonal tests ( PAC/ PRA) prior to CT imaging </li></ul><ul><li>Spironolactone as medical therapy </li></ul><ul><li>CT may show adrenal adenoma </li></ul><ul><li>Call surgical consult </li></ul><ul><li>If accepted, order adrenalectomy </li></ul>
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