CCS cases: overview

LOGICAL APPROACH TO ANY CCS CASE : Take a deep breath and select ?Start Case? button to
begin. You will see the case introduction. Wait! Note on the
erasable board: Setting
Age of the patient
Race of the Patient
Sex of the patient Then click ?OK? and you will see the initial vital
signs. Wait! Note on the erasable board: Stable or unstable? Then click ?OK? and you will see the initial history.
Wait! Think and write on the erasable board: Differential Diagnosis :
Allergies
Habits ? smoking , alcohol , drugs , etc. Anything
worrisome? Then ask: Is the patient stable or is it an emergency? A clue to
this would be in the history - for emergency cases,
you will see only the basic history of present illness
and not the detailed history (social, past, etc). All
other history will be ?unobtainable?. If unstable, do a EMERGENT physical exam. No emergency
case should get a full physical exam - it?s an
emergency!! For the EMERGENT physical, choose the 'general
appearance' and the relevant system. If needed, add
one or two relevant systems. After you note the results of the EMERGENT physical,
stabilize patient immediately: Airway ? Intubation?
Breathing ? Oxygen mask? Chest tube?
Circulation ? IV fluids? Dopamine?
Drugs ? Naloxone? Dextrose? Thiamine?
IV Access? Then ask: Does the patient?s condition correlate to the setting? Emergency or unstable patient in office needs to go to
the ER immediately!! Change location if necessary. After the patient is stable and in the right setting,
proceed to ?Interval/follow-up history? and a more
detailed RELEVANT physical exam. If the patient is already a stable case in the right
setting, proceed straight to the RELEVANT physical
exam. Then ask: Is the case limited to one particular system? Like
Asthma or MI? Choose the particular system and a few related
systems, based on the most likely diagnosis. Is the case not limited to one particular system? Choose a COMPLETE physical exam. This option is
available on the top of the physical exam choices.
Examples of such cases include Case for Annual
Physical Exam, Child Abuse, Depression, Asymptomatic
Hypertensive for Office Management, etc. Note the significant findings on the physical exam and
go back to your erasable paper and revise your
Differential Diagnosis. Strike out those which are
less likely and add those are more likely. Then keeping the Differential Diagnosis in mind,
consider the labs to be done. When considering labs use this mnemonic: I B U O P I ? Imaging ?> X-Rays, CT, USG, MRI, Echo, Scopy, VQ
Scan, etc. B ? Blood ?> CBC, Basic Metabolic Panel, Lipid
Profile, LFT, Smears, Cultures, etc. U ? Urine ?> Urinalysis, Toxicology Screen, Ketones,
etc. O ? Others ?> Other tests which do not fall under IBU,
like EKG, PEFR for Asthma, Pulse Oximetry, Biopsies,
etc. P ? Pregnancy test ?> For any female of reproductive
age presenting with abdominal or pelvic symptoms, or
trauma. When ordering labs, consider: Is this test time-effective/time-consuming? Choose
time-effective. Is this test initial screening/confirmatory? Choose
initial screening. Is this test cheap/expensive? Choose cheap. Is this test non-invasive/invasive? Choose
non-invasive. Then ask: Will this test tell me anything useful? Tests like
CBC, ESR, Chem 7, etc might satisfy the above criteria
but will not tell you anything useful. Are there any specific tests for this condition?
Examples are Cardiac Enzymes for MI, Sweat Chloride
test for Cystic Fibrosis, etc. Are the tests in the right order? Example ? Pulse
Oximetry before ABG, CT before Spinal Tap, etc. Order the labs using the Order button. Then advance clock to the ?Next Available Result?. Understand the results. Ask: Is the diagnosis clear or do I need any confirmatory
tests? If diagnosis is clear, start treatment. If confirmation is needed, order confirmatory tests
and then start treatment. Treatment : Determine if the patient is in the right setting. If
patient is in office and needs to be admitted, change
location to ward. If patient is in ward and is in a
serious condition, change location to ICU. If case is admitted, order: IV access (unless IV drugs are not indicated) ? Type
?IV Access?. Vital Signs ? Type Vitals and click on ?Every 1,2, 4
or 6 hours? depending on the condition of patient. Activity ? Type ?Bed Rest? and choose ?Complete bed
rest? or ?Bed rest with bathroom privileges? or type
restrain and choose ?Restrain patient in bed?. Diet ? Normal, liquid, NPO, 2 gram Sodium, ADA, etc.
Order ?Diet? and you will see the list of options,
choose which is the best for this case. Tubes ? NG Tube? Foley?s catheter? Fluids ? Saline, Ringer, etc. Type ?Fluids? and choose
which is the best for this case. Urine output ? Type ?Urine Output? and choose
frequency. There is no option for Input/output chart. Medications : Stop! Check for allergies on erasable board! Order standard drugs for this case. Decide IV or Oral. Decide bolus or continuous. Decide
frequency. Labs : Additional labs to confirm diagnosis? Labs to monitor? Cardiac Monitor? Pulse Oximetry? Consults : Order consults if necessary. GI, Ophthalmology,
Psychiatry, Genetics, Social worker, etc. Then move clock! Depending on severity of case, move by 30 minutes/1
hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1
week. Do Interval/follow-up history. Understand the results of the labs. Then ask: Has the patient?s condition changed significantly? If yes, change locations. If the condition has improved, move the patient to the
next location in the order ER --> ICU --> Ward -->
Office/Home. If the condition has worsened, move the patient to the
next location in the order Home/Office --> Ward/ER or
Ward/ER --> ICU. If you are changing location from inpatient
(ER/ICU/Ward) to outpatient (Office/Home): Stop unnecessary medications and change IV medications
to oral.
Discontinue IV fluids.
Remove tubes.
Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant.
Patient education or counseling or diet specific and
vital to this case. Type ?patient education? and
?counsel? and see if anything is relevant to this
specific case. Type ?Diet? and see if anything is
relevant to this specific case. By this time, the 5 minute screen will appear! Then type ?counsel? and choose the relevant things.
You can choose multiple things at a time. See your
erasable board for any worrisome habits like alcohol
or smoking! Type ?patient education? and choose the relevant
things. You can choose multiple things at a time. Patient education / Counseling options : Every adult person - Drive with seat belt, Exercise
program, No illegal drug use. Every person taking long-term medications - Medication
compliance, Side effects of medication. Every person who takes alcohol - Limit or stop alcohol
intake. Every person who smokes - Smoking cessation. Every person of reproductive capacity - Safe sex
techniques. Every person with long-term conditions,
life-threatening allergies, chronic illnesses - Medic
Alert Bracelet. Female requesting contraception or practicing unsafe
sex - Birth control, Contraception, Safe sex
techniques. Cancer case - Cancer diagnosis. Asthmatic - Asthma care, medication compliance. Terminal case - Advance Directive (Family), Advance
Directive (Patient) and Living will. Every post-operative case - Deep breathing and
coughing Diabetic - Diabetic foot care, Home glucose
monitoring, Diet. Learning disorder kid - Educational remediation. Osteoporosis - Estrogen replacement therapy. HIV case - HIV support group, safe sex techniques. Hypothyroidism or endocrine case - Hormone replacement
therapy. Lactose intolerance - Limit cow's milk intake, Diet. GI bleeding, peptic ulcer case - No aspirin, Sit
upright after meals. Old age, epileptic, vision defects, narcolepsy - No
driving. Anxiety case - Relaxation techniques, Rebreathing into
a paper bag. Violent psychotic case - Restraining order. Spousal Abuse - Safety plan. IV drug use - No illegal drug use, SBE prophylaxis,
Safe sex techniques, Stop alcohol, Smoking cessation. Pelvic surgery - No intercourse. STD - Safe sex techniques, Sexual partner needs
treatment. Depression - Suicide contract. Routine screening : Schedule appropriate screening
tests as per age. Type the relevant test and schedule. Immunizations : For Pediatrics and Geriatrics as
relevant. Type ?Vaccine?, choose and schedule. At the end of the 5 minutes: Type the Final Diagnosis. ------------------------------------------------------------------------------------------------------------ Golden Notes for CCS: 1.If a patient has a fever, give acetaminophen (unless
it is contraindicated)
2. If a patient is on a statin or you order a statin,
get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a
TSH
4. If a patient is going to surgery (including cardiac
catheterization), make them NPO
5. All NPO patients must also have their urine output
measured (type "urine output")
6. If a woman is between 12 and 52 years old and there
is no mention of a very recent menses (that is, < 2
weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no
longer required (especially if you are sending the
patient home)
8. When a patient is stable, decide whether or not you
should change locations (if you anticipate that the
patient could crash in the very near future, send the
patient to the ICU; if the patient just needs
overnight monitoring, send to the ward; if the patient
is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an
HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an
ophthalmology consult (to evaluate for diabetic
retinopathy)
11. In any patient with respiratory distress
(especially with low oxygen saturations), order an ABG 12. In any overdose, do a gastric lavage and activated
charcoal (no harm in doing so, unless the patient is
unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get
"suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get
Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood
Type and Crossmatch (just in case they have to go to
the O.R.)
17. In any pregnant patient, get "Blood Type and Rh"
as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI
bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or
is at risk for aspiration, order "head elevation" and
"aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and
use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO
and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral
hypoglycemic agents, start insulin, HbA1c, advise
strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown
etiology get a "fingerstick glucose" check (for
hypoglycemia), IV thiamine, IV dextrose, IV naloxone,
urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a
reticulocyte count
26. If you administer heparin, check platelets on Day
3 and Day 5 (for heparin-induced thrombocytopenia), as
well as frequent H&H
27. If you administer coumadin, check daily PT/INR
until it is within therapeutic range for two
consecutive days
28. Before giving a woman coumadin, isotretinoin,
doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it
depletes K+)
30. All children who are given gentamycin, should have
a hearing test (audiometry) and check BUN/Cr before
and after treatment
31. Don't forget about patient comfort! Treat pain
with IV morphine, nausea with phenergan, constipation
with PO docusate, diarrhea with PO loperamide,
insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with
IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as
those who are pre-op), get "pneumatic compression
stockings"
34. If fluid status is vital to a patient's prognosis
(such as those with dehydration, hypovolemia, or fluid
overload), place a Foley catheter and order "urine
output"
35. If a CXR shows an effusion, get a decubitus CXR
next
36. If you intubate a patient you ALSO have to order
"mechanical ventilation" (otherwise the patient will
just sit there with a tube in his mouth!)
37. With any major procedure (including surgery,
biopsy, centesis), you MUST type "consent for
procedure" (typing consent will not reveal any
results)
38. With any fluid aspiration (such as paracentesis or
pericardiocentesis), get fluid analysis separately (it
is not automatic). If you don't order anything on the
fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal
arteritis), give IV ranitidine, calcium, vitamin D,
alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and
ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no
need for insulin), in addition to IV normal saline and
thiamine
42. All patients over 50 with no history of FOBT or
colonoscopy should get a rectal exam, a FOBT, and have
a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly
clinical breast exam and mammogram (if risk factors
are present, start at 35)
44. All men > 50 years old should get a prostate exam
and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise
"advanced directives"
46. In any patient with a chronic disease that can
cause future altered mental status, type "medical
alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool
checked for "ova and parasites", "white cells",
"culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have
their levels checked
49. All patients with suspected MI should be given a
statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a
direct Coombs test
51. Schedule all women older than 18 for a Pap smear
(unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done:
?NPO?, ?IV access?, ?IV normal saline?, ?blood type
and crossmatch?, ?analgesia?, ?PT?, ?PTT?, ?pneumatic
compression stockings?, ?Foley?, ?urine output?,
?CBC?, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in
anaphylaxis), and he/she is on a beta-blocker, give
glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be
advised ?no driving?
56. To diagnose Alzheimer?s, first rule out other
causes. Order a CT head, vitamin B12 levels, folate
levels, TSH, and routine labs like CBC, BMP, LFT, UA.
Also, if the history suggests it, order a VDRL and HIV
ELISA as well
57. Also rule out depression in suspected dementia
patients
58. For all women who are sexually active and of
reproductive age, give folate. In fact, you should
give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and
have NG suction so that no food can stimulate the
pancreas
60. Send patients home on a disease-specific diet:
diabetics get a ?diabetic diet?, hypertensives get a
?low salt diet?, irritable bowel patients get a ?high
fiber diet?, hepatic failure patients get ?low protein
diet?, etc
61. Do not give a thrombolytic (tPA or streptokinase)
in a patient with unstable angina patient
62. Patients who are having a large amount of
secretions, order ?pulmonary toilet? to reduce the
risk of aspiration
63. Every patient should be advised to wear a
?seatbelt?, to ?exercise?, and advised about
?compliance?
64. In any patient who presents with an unprotected
airway (as in overdoses, comatoses), get a CXR to rule
out aspiration
65. In any patient with one sexually transmitted
disease (such as Trichomonas), check for other STDs as
well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and
do a Pap smear in all women with an STD
66. Remember to treat children with croup with a ?mist
tent? and racemic epinephrine
67. Any acute abdomen patient with a suspected or
proven perforation, give a TRIPLE antibiotic:
Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic
anemia if the cause is unknown. Order ?iron?,
?ferritin?, ?TIBC?
69. Women with vaginal discharge should get a KOH
prep, saline (wet) prep, vaginal pH, cervical
gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check
her fasting glucose
71. When the 5 minute warning screen is displayed, go
through the following mnemonic (RATED SEX). I know it
probably is not the best mnemonic, but it is difficult
to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (?patient education?)
X (stands for safe seX)
72. All suspected child abuse patients should be
admitted and you should order THREE consults: consult
?child protection services?, consult ?ophthalmology?
(to look for retinal hemorrhages), consult
?psychiatrist? (to examine the family dynamics)
73. When a woman reaches menopause, she should have a
?fasting lipid profile? checked (because without
estrogen, the LDL will rise and the HDL will drop), a
DEXA scan (for baseline bone density), and of course,
FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if
pancreatic cancer, order CA 19-9; if ovarian cancer,
order CA 125.
75. Remember to give ?phototherapy? to a newborn with
pathologic unconjugated bilirubinemia (it is not
helpful if it is predominantly conjugated). Also, with
phototherapy, keep the neonate on IV fluids (the heat
can dehydrate them), and give erythromycin ointment in
their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides,
check ?amylase? and ?lipase? (high triglycerides can
cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who
develops a fever is SEPSIS until proven otherwise.
Admit to the ward and culture EVERYTHING: ?blood
culture?, ?urine culture?, ?sputum culture?, and even
?CSF culture?. And give antibiotics to cover
EVERYTHING.
79. If you get a high lead level in a child, you have
to check a ?venous blood lead level? to confirm. If
the value is > 70, admit immediately and begin IV
?dimercaprol? and ?EDTA?. Order ?lead abatement
agency? and ?lead paint assay? upon discharge.
80. If you perform arthrocentesis, send the synovial
fluid for ?gram stain? and the 3 Cs: ?crystals?,
?culture?, and ?cell count?
81. If a patient has exophthalmos with
hyperthyroidism, it is not enough to just treat the
hyperthyroidism (as the eye findings may worsen). You
should give prednisone.
82. If any patient has cancer, get an ?oncology
consult?.
83. In a patient with rapid atrial fibrillation,
decrease the heart rate first (then worry about
converting to sinus rhythm). Use a CCB (diltiazem) or
a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation,
make sure you check a TSH
85. In any patient with suspected fluid volume
depletion, order ?postural vitals? to detect
orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you
should prepare the bowel: make the patient NPO, give
IV fluids (if necessary) and order ?polyethylene
glycol?.
87. Any patient with Mobitz II or complete heart block
gets an immediate ?transcutaneous pacemaker?. Then
order a cardiology consult to implant a ?transvenous
pacemaker?
88. If calcium level is abnormal, order a ?serum
magnesium?, ?serum phosphorus?, and ?PTH?
89. Treat both malignant hyperthermia and neuroleptic
malignant syndrome with ?dantrolene?
90. All splenectomy patients get a ?pneumovax?, an
?influenza? vaccine, and a ?hemophilus? vaccine if not
previously given.
91. If you give INH (for Tb), also give ?pyridoxine?
(this is vitamin B6)
92. If you give pyrazinamide, get baseline ?serum uric
acid? levels
93. If you give ethambutol, order an ophthalmology
consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate),
send the EFFUSION as well as a peripheral blood sample
for: LDH and protein (to help differentiate a
transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic
penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction
(for any reason), should get ?skin test? for allergens
(to help prevent future disasters) and consult an
allergist
97. Do not give cephalosporins to any patient with
anaphylactic penicillin allergies (there is a 5%
cross-reactivity)
98. Order Holter monitor on patients who have had
symptomatic palpitations.
99. Any patient with a first-time panic attack gets a
?urine toxicology? screen, a TSH, and ?finger stick
glucose?
100. All renal failure patients get: ?nephrology
consult?, ?calcium acetate? (to decrease the
phosphorus levels), ?calcium? supplement, and
erythropoeitin -----------------------------------------------------------------------