From Mid-Feb2012; there will be 12 CCS cases as follows:

8 cases with Real time of 20 minutes each.

4 cases with Real time of 10 minutes each.
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 .
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.
5. 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. 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.
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 patients
initial H & P as well as updates are stored under this section.
6. 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
7. New Changes To CCS -2012
REAL TIMES:
20 minute cases :
18 minutes for active screen and 2 minutes for Case-end screen.
10 minute cases :
8 minutes for active screen and 2 minutes for
Case-end screen.
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 !
New changes do not change anything else! No change in scoring parameters or software navigation or
appearance
8. Real Time
Real time the time on the bottom of the screen on the right side.
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.
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.
9. Case end (2-minute screen)
You cannot do certain steps on 2-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 2 Minute screen.
Prioritize your 2-minute screen orders in the following order.
Add any needed orders to be done NOW
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 patients 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).
Add any tests or orders or follow-up monitoring relevant to the patients
current presentation to be done in LATER . LATER refers to future
simulated time which you can select using the calendar.
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!
Schedule Screening tests for a Later date
10. 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.
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.
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 your goals, know your monitoring parameters and 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.
11. Areas that are scored
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.
12. Areas that are scored
Most important areas that are scored:

Diagnosis ( history and physical exam, appropriate diagnostic tests. Focused physical
only when patients are unstable)
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. )
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)
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 )
Monitoring ( Once you treat a patient, MONITOR!! Thats 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

13. 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. ( Doing complete physical is regarded as poor
management in unstable cases)
Fast treatment first stabilize. After stabilizing and after treating adequately , you can proceed with
complete physical ( do not forget it!)
14. 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
15. Initial Step in Shock Suspected cause of Shock History clues Physical clues Initial therapy Hypovolemia
MVA with bleeding
Dehydration
Diarrhea
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
Orthostatic hypotension
( you have to order this
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 ( Dont wait for CBC) Distributive shock
- Clues to anaphylaxis
Clues to infection ( fever on vitals screen)
Clues to drug use
Fever may point to septic shock
Wheals - anaphylaxis
Always, IV Normal saline Stat ( 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
16. 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)
17. Sepsis
Know the definition of SIRS Systemic Inflammatory Response Syndrome. SIRS is indicated by
at least two of the following:
Fever or hypothermiatemperature 38C or higher or 36C 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)
18. 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)
19. 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 Norepinephrine. If your patient has a low output state, use Dopamine.
Early antibiotics to address the presumed source
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. 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. 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!)
23. Pain
Consider Pain as the fifth vital
Addressing severe pain immediately is extremely important .
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.

Most ER pains, can use Morphine if severe

Pain in office follow analgesic ladder
24. 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
25. 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)
26. Basic set of ER orders
Vitals
Oxy ( pulse ox, oxygen)
IVA ( IV Access)
EKG
Cardiac monitor
Urinalysis
BMP ( CMP takes 2 hours, BMP 30 minutess. If you need LFTs order them separately rather than
ordering a CMP)
CBC
Checking interval history often is a type of monitoring
Dont 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
27. Indications for ICU admission
Shock
Respiratory failure
Post op 24 hours in some cases
Post MI
DKA/ Refractory electrolyte abnormalities
Acute delirium/ altered mental status
28. 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)
Neurochecks if disoriented
Suction airway if comatose or disoriented
29. Time required and Invasiveness tests in ER
TIMING & INVASION
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
30. Unresponsiveness in ER
Get basic stuff quickLY :
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
after giving dextrose). Look and exclude rapidly reversible causes of coma by
using history, physical and lab tests
( hypoglycemia, opiod overdose, BZD overdose, hepatic encephalopathy etc)
before you prophylactically intubate for airway protection in coma
- fingerstick glucose stat (Accucheck),
- 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, finger stick glucose very high with delirium as in DKA or
HONK)
31. 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
Obtain consent for procedure
IV access
Type and crossmatch
PT, PTT
Name of the procedure itself ( eg: hysterectomy, adrenalectomy e.t.c)
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 !
32. Using keywords
Oxy
Cou
Stop
Avoid
Diet
Fluids
Advise
Vacci etc
33. Advancing clock

Advance only after putting appropriate orders

If you do not advance you will use up your real time without nothing happening with the patient
If you do not advance , it means you have not implemented the orders you wrote
Advance clock to get results when needed
34. Before advancing clock!
Think twice is there anything else that needs to be done, Esply true for ER Cases
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.
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.
35. Stop Clock Function
Stop the clock function is a critical step.
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.
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.
The following is very important and can affect your score in Office Cases:
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).
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;
36. Using control button
You can select multiple orders by using control button so that u dont waste much time
37. Diet orders
Order appropriate diet for admissions
Type diet to select what you need in your case
38. Follow up & Interval Hx
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.

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
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 2 min screen
39. Follow up appointments
Schedule follow up appointments for office visits where required and then advance clock to get them
back in your office.
Take follow-up history each time you visit an inpatient or during out-patient follow up
40. Counseling
Needed in all office visits
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 .
Type counsel press control and then select what you need at the end of the case.
Routine counseling may not be scored at all after 2 min screens are introduced.
Counsel on appropriate issues
- 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 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).
41. 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 2-minute screen by scheduling them for a later
date.
42. 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)
43. Indications for admission in an office visit
Location
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.
44. Sending Patient home from Office
Location
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.
45. Moving the Patient
LOCATION
Can not use transfer to icu order on the 2 min screen
Moving the patient 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
46. 2-minute screen
You cant change location or obtain results
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!
If you did not have time to put your essential treatment orders and the case ended , put them now
Discontinue unnecessary orders at this time ( if unnecessary at that point simulated time )
Add discharge home medications if patient simulated time and if patient clinical situation meets
discharge criteria.
If patient is ready to go home, switch IV meds to oral
Do counseling
Is your patient eating?- if not already put , enter diet orders.
Monitoring for later date : VERY IMPORTANT ( you can do this only on 2 min screen) enter followup 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
47. Use control button Save Real time
Arthrocentesis orders
Fluid analysis orders
Counseling orders on the 2 min screen
Other orders like:
diabetic
cardiac
Oxy etc
48. Do not waste time staring at the screen Save Real time
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.
You must practice thoroughly.

You need to be very fast with navigation

Master Archer strategies and practice them several times.
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!
49. Cases ending before time
Why do many cases end quickly? how will I know if I did well if case ended quickly ?
That is the reason why you need to check interval history and vitals often.
This is the reason you need to monitor your laboratory or clinical parameters (physical, vitals) pertinent
to that case
If monitoring parameters are improving and if case ended before allotted real time, it means you have
done very well .
If monitoring parameters are deteriorating and if case ended before allotted real time, it means you
have NOT done well.
50. Checklist
Imaging & EKG
o
EKG, EEG, Echo, Ultrasound, Carotid Doppler
o CXR, X ray Joints, acute abdominal series
o 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.
51. Checklist
Labs:
CBC, CMP, Urine routine, TSH, Lipid Profile, Cardiac enzymes, ABG, Glucometer check, Drug levels,
Toxicology screen-Urine and serum, ANA, ESR.
o Bleeding & pre-op pts Type Blood and cross match, PT/INR, PTT.
o Infections cultures of Blood, Urine, Sputum or CSF, as appropriate.
o Acute abdomen order amylase, lipase, b HCG & acute abdominal X ray series.
52. Dyspepsia
- If warning signs or age > 50, please do EGD
If doing EGD, add biopsy, gastric mucosa H.pylori stain.
53. 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
54. 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
55. 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
56. Shock
57. Respiratory Failure
58. 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
59. 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
60. Delirium in Elderly
Sun downing
Dementia
Sepsis : UTI, Pneumonia and C.difficle
61. 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
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