CCS Workshop

1. 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 the trademarks owned by USMLE Galaxy, LLC

2. Webinar – Muting/ Unmuting WELCOME! We will begin as soon as all the attendees arrive! Thank you! 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. 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

3. 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.

4. 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

5. “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 cannot change patient location • you cannot advance the clock • you cannot discharge the patient • you cannot obtain results • you 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

6. “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.

7. 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!)

8. 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

9. Initial Step in Shock

10. 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)

11. 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)

12. 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)

13. 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

14. Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case

15. ER Setting – A simple approach

16. 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!)

17. 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”

18. 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

19. 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 disease-specific tests) • Specific Treatment ( if you are pretty sure)

20. 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

21. Indications for ICU admission • Shock • Respiratory failure • Post –op 24 hours • Post MI • DKA/ Refractory electrolyte abnormalities • Acute delirium/ altered mental status

22. 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)

23. 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

24. 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)

25. 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)

26. Using keywords • Oxy • Cou • Stop • Avoid • Diet • Fluids • Advise • Vacci etc

27. 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

28. 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.

29. Using control button • You can select multiple orders by using control button so that u don’t waste much time

30. Diet orders • Order appropriate diet for admissions • Type “diet” to select what u need in your case

31. 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

32. 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

33. 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

34. 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.

35. 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)

36. 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.

37. 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.

38. 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

39. 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

40. Use control button – save time • Arthrocentesis orders • Fluid analysis orders • Counseling orders on the 5 min screen

41. 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

42. 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. 

43. 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. 

44. Dyspepsia - If warning signs or age > 50, please do EGD If doing EGD, add biopsy, gastric mucosa – H.pylori stain.

45. 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

46. 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

47. 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

48. Shock

49. Respiratory Failure

50. 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