Archer USMLE Step 3

CCS Workshop
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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 attendees 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

New Changes To CCS -2012

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 15th 2012, will only
get the new version .
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.

New Changes To CCS -2012

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.
Prior to Mid-Feb 2012, examinees are given 9 CCS cases with 25
minutes REAL time.
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.

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.

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

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

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.

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

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.

Components 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.

Components that are scored

q Most important areas that are scored:

v Dont forget these! : Dance Like The Movie Stars ( DLTMS)

Diagnosis ( history and physical exam, appropriate diagnostic tests. Focused physical only
when patients are unstable)
Location ( Location of your treatment and evaluation. Unstable cases s hould 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 c onsult. This is just an example!
Sequencing will be demonstrated more in our practice c ases. Correct Sequencing is extremely
important )
Monitoring ( Once y ou 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 c omplex 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

Vitals first

ER Setting

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!)

Shock
Shock defined as SBP < 90 or MAP < 65
Different types of Shock
Hypovolemic shock
Distributive shock
Septic Shock
Anaphylactic Shock
Opiod Overdose

Cardiogenic Shock
Right Ventricular MI
Left Ventricular MI
Cardiac tamponade
VSD/ Papilalry muscle rupture post MI

Obstructive Shock
Tension Pneumothorax
Pulmonary Embolism
Air Embolism
Cardiac Tamponade

Initial Step in Shock

Suspected c ause
of Shock

History c lues

Physical c lues

Initial therapy

Hypovolemia

-MVA with bleeding

-Orthostatic hypotension

-Dehydration

-( y ou have to order this

IV Fluid NS boluses
If suspecting hemorrhagic
shock order Type and c ross
match and blood transfusion
right away ( Dont wait for CBC)

-Diarrhea
-Vomiting
-Vaginal bleeding

Remember, Strong c lues from history & v itals r eveal Shock

Proceed to order s heet
No c lues from history do 2 minute physical, to evaluate the
cause of s hock ( add abdomen to focused physical if history
suggestive) doing 2 minute physical will determine y our next
life saving s tep here

on the screen)
-Dry oral mucosa
-Tachycardia
-Stool guaic positive
-Gross bleeding
-Abdominal signs s uggesting

bleeding or perforation or
peritonitis
-Heavy Vaginal bleeding

Distributive
shock

- Clues to anaphylaxis
-Clues to infection ( fever on vitals s creen)
-Clues to drug use

-Fever may point to s eptic s hock

-Wheals - anaphylaxis

-Always, IV Normal s aline Stat (

Obstructive
Shock

- Chest pain/ s ob can indicate tension pneumothorax, c ardiac

tamponade or PE history c lues are not v ery s uggestive
proceed to 2 minute physical

2 minute physical ( RS, CVS)

-Reveals absent breath s ounds
Tension pneumothorax
-Reveals pulsus paradoxus, J VD
Cardiac tamponade
-Reveals normal physical +
-historical c lues suspect PE

After 2 minute
Physical, order life s aving s tep
Pneumo chest tube
Tamponade pericardiocentesis
& then window
PE Spiral c t and then tpa,
hold heparin
Air trendelenberg position

Cardiogenic
shock

Chestpain, s ob

2 minute physical make s ure

chest is c lear. If r ales Left
ventricular MI. Then get EKG

If chest c lear IV Fluids. If

rales hold IV fluids, GET
EKG, then IABC and c ardiac
cath. O rder other MI
management

fill up the SVR)

- Epinephrine if anaphylaxis
-Antibiotics if Sespsis

Respiratory Failure
Respiratory Rate > 30 unstable, tachypnea
Address it STAT
If you have a clue, go straight to order sheet ( hx of Asthma, COPD,
PE clues)
If no clues from history or associated with chest pain do 2 minute
physical ( R.S, CVS) eg : D/D includes Tension pneumothorax,
pulmonary edema, MI with pulmonary edema, PE. By doing a 2
minute exam, you can order the stabilizing and life saving step
within 2 minutes of Simulated time . At 2 minutes of simulated time:
Chest tube if pneumothorax ( don not wait for CXR)
Pericardiocentesis if cardiac tamponade
CT chest and tpA if highly suspected PE
Morphine and furosemide if Acute Pulmonary Edema
Nebulizations ( Albuterol + Ipratropium) and corticosteroids if
asthma/ COPD exacerbation ( wide spread wheezes, accessory
muscle use)

Get ABGs in all cases of respiratory failure ( other place

where ABGs are needed is when you see low metabolic
abnormalities on BMP you need to know Ph here)

Sepsis
Know the definition of SIRS Systemic Inflammatory Response
Syndrome. SIRS is indicated by at least two of the following:
Fever or 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)

Sepsis
Sepsis : To diagnose Sepsis, there should be a presumed or known s ite of infection +
evidence of a systemic inflammatory response ( SIRS)
A presumed or known s ite of infection is indicated by one of the following:
Purulent sputum or endotracheal secretions ( finding from history)
Physical exam with neck stiffness, altered mental status or no other source of
sepsis suspect meningitis
chest x-ray with new infiltrates that can not be explained by a noninfectious
process
Radiographic or physical examination evidence of an infected collection ( CT
showing abscess or physical revealing reduced breath sounds or an
abdominal mass or abscess or joint swelling)
Presence of leucocytes in a normally sterile body fluid ( Ascites with > 250
neutrophils is SBP)
Positive blood cultures
Suspicion of Clostridium difficle from previous use of antibiotics in the past 3
months pr recent hospitalization or previous history of C.difficle
Urinalysis showing positive leuco-esterase or nitrite and WBCs especially, when
associated with urinary symptoms
When you have SIRS and you Presume that there might be infection please DO NOT WAIT!
Start presumptive therapy with antibiotics ( but you should have a rationale regarding the
presumed source. Example: Patient has SIRS and urine leucoesterase is positive, no other
source identified immediately it is absolutely fine to presume that Sepsis is possible and the
presumed source is UTI so, please get cultures ( blood and urine) and start antibiotics right
away pending cultures. ( do not wait for cultures to come back to start antibiotics)

Septic Shock
Suspicion or evidence of sepsis + Shock
Follow quick sepsis guidelines
ABC
Oxygen
Continuos B.P monitoring
Pan cultures
IV FLUIDS NS MOST IMPORTANT
If BP does not improve, add a pressor. If your patient is
tachycardic, choose Nor-epinephrine. If your patient has a
low output state, use Dopamine.
Early antibiotics to address the presumed source

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

Presumed or Known site of
infection

Possible Bugs

Emperical therapy

Community acquired pneumonia

S.pneumoniae, Legionella, mycoplasma,

H.influenzae

Third generation c ephalosporin +

macrolide or Newer Quinolone

Early Hospital Acquired Pneumonia ( < 5

days)

Gram negative rods non resistant (

e.coli, proteus, k lebsiella), 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 Use good anerobic c overage :

(B.fragilis)
Cipro+flagyl, Pip/tazo, Ertapenem,
Imipenem. Do not use c ephalosporin
alone ( add metronidazole if using it)

Urinary tract infections

E.coli, proteus
Enterococci

Quinolone, c eftriaxone, extended

Meningitis

S.pneumonia, H.influenzae,
N.meningitidis, E.coli. In ages < 1month
or > 50 y ears -Listeria

Vanco+Ceftriaxone. If listeria s uspected,

add Ampicillin. Give Dexametasone prior
to antibiotics

Pseudomembranous c olitis/ C.Difficle

Diarrhea

c.difficle

Metronidazole p.o. I f resistant, use v anco

p.o ( do not use I.V v anco not effective)

spectrum beta lactums, if enterococci is

present use ampicillin or v ancomycin

ER Setting A simple approach

Presenting Issue

Next Step on CCS

Vitals are v ery unstable + y ou, absolutely, have no c lue

about the diagnosis from the history

Go t o physical s creen do a v ery focused physical ( 2

minutes Chest and Cardiovascular. Consider abdomen
only if history revealed abdominal pain or trauma)
Proceed to order sheet (Remember that when y ou have
no clue from the history, a Life s aving s tep for a
severely unstable v ital may not be identified until y ou do
the 2-Minute ( Chest, Cardiovascular) physical).
Remember that if this s tep is done early ( less Simulated
time), you will get maximum score

Vitals are UNSTABLE ( Shock or respiratory failure) +

you have a c lue about the diagnosis from the history

Proceed to Order sheet and try to s tabilize. Write

Stabilizing orders, Basic orders, Symptom relieving
orders. Write Specific diagnostic tests and Specific
treatment s ince y ou already have a c lue about the
diagnosis from the history ( Some examples: Anaphylactic
shock, Hypovolemic s hock from MVA , s trong c lues of
PE in the history )

Vitals are Stable no Pain

Full physical and then go to order sheet

Vitals s table but History reveals s evere pain

Address pain first and then c ome back to physical s creen

( except in abdominal pain do abdomen exam first and
then address pain)

ER setting
In most ER cases, you can proceed to the order
sheet to stabilize your patient or to treat the
severe symptoms. But sometimes you do not
have a clue about the diagnosis and your patient
may be crashing in such cases, do a 2 minute
physical exam to formulate your differential
diagnosis for shock or respiratory failure ( A
focused exam of CVS and RS may give you a
great clue regarding the diagnosis and at 2
minutes, you will be able to offere a definitive
treatment for your patient!)

Pain
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

ER Setting
Admission if required move patient to
ward or ICU
Criteria for admission to the ICU shock,
resp failure, DKA, Acute MI, Refractory
electrolyte issues, Acute delirium

General Approach
Stabilization orders
Basic Tests
Symptomatic treatment ( address signs
also)
Specific diagnostic tests ( if you have a
clue from the history. If not please do
focused physical before ordering disease-
specific tests)
Specific Treatment ( if you are pretty sure)

Basic set of ER orders

Vitals
Oxy ( pulse ox, oxygen)
IVA ( IV Access)
EKG
Cardiac monitor
Urinalysis
BMP ( CMP takes 2 hours, BMP 30 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

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

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

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

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)

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, c ardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eye
procedures, ENT s tuff, 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!

Using keywords
Oxy
Cou
Stop
Avoid
Diet
Fluids
Advise
Vacci etc

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

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.

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 -
"Stop the clock" or Continue". 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 "continue" 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" after the r esult is very important in office cases scenarios as well. When the patient is at

"Home", 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 "Stop the clock" and put in further tests or
common oral treatments on the order sheet even though patient's location is showing at "HOME". 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 "Stop the
clock" and change the patient location to "ER" 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 "Stop the clock" button previous appointment will be cancelled. You m ust
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 "

Using control button

You can select multiple orders by using
control button so that u dont waste much
time

Diet orders
Order appropriate diet for admissions
Type diet to select what you need in your
case

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

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

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).

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.

Invasiveness of investigations
You will not get penalized for ordering an
unnecessary non invasive investigation.
However, sometimes what seemed initially
unnecessary might give you useful information (
LFTs, Chem7)
Do not order EGDs, Intubation, Colonoscopies,
ERCPs, Chest tubes, CT with contrast if they are
not very much needed they are invasive and
could be harmful.
For most invasive investigations you need
consults ( cardiac cath, colonoscopy, EGD,
ERCP)

Indications for admission in an

office visit

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.

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.

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

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 follow-up tests at a later date i.e; following drug
toxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INR
monitoring etc), following disease activity ( follow up TSH etc)
Enter elective screening tests for a LATER date in an inpatient
i.e; colonoscopy, pap smear, mammogram
Enter age appropriate and disease appropriate vaccines if not entered
before

Use control button Save Real time

Arthrocentesis orders
Fluid analysis orders
Counseling orders on the 2 min screen
Other orders like:
diabetic
cardiac
Oxy etc

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!

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.

Checklist
Imaging & EKG
EKG, EEG, Echo, Ultrasound, Carotid Doppler
CXR, X ray Joints, acute abdominal series
CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.

Nursing orders
NPO, Diet, IV Fluids, Vitals, Input/output, Physical
therapy
Tubes- NG, Foley
Pulse oximetry & Oxygen, cardiac monitor
Medication orders
Counseling
Weight loss, exercise, diet, smoking & alcohol
cessation.

Checklist
Labs:
CBC, CMP, Urine routine, TSH, Lipid Profile,
Cardiac enzymes, ABG, Glucometer check,
Drug levels, Toxicology screen-Urine and
serum, ANA, ESR.

Bleeding & pre-op pts Type Blood and cross

match, PT/INR, PTT.
Infections cultures of Blood, Urine, Sputum or
CSF, as appropriate.
Acute abdomen order amylase, lipase, b HCG &
acute abdominal X ray series.

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

Diarrhea
Make an attempt to calssify
Infalmmatory vs. Non inflammtaory.
If inflammatory, is it bacterial or non bacterial?
Get stool wbc, occult blood and bacterial cultures as
main work up in acute diarrhea work up

Acute MI
EKG will decide further Mx
EKG will take 15 mins
Thrombolytics vs. cardiac Cath
What if similar to dissection? Think of your
Triad
Pericarditis the EKG differences. Look
reciprocal depressions are not seen in
pericarditis

Stroke
TIA Thrombotic vs.Embolic
CT head with out contrast
ASA vs. Aggrenox
EKG, 2D Echo to r/o cardiac origin
Carotid doppler to r/o carotid stenosis
If carotid stenosis and meets criteria ? CEA

Shock

Respiratory Failure

Polymyalgia Rheumatica
Exclude other differential diagnosis
Get an ESR. ESR > 100 very suggestive of polymyalgia in
presence of typical clinical features
Temporal aretery biopsy if suggesting associated temporal arteritis.
Get baseline DEXA if starting steroids
Prevent osteoprorosis if starting steroids

HUS
Diarrhea preceding Presentation
R/o other causes of microangiopathic hemolysis
Demonstrate schistocytes on peripheral smear
Supportive theray as initial choice
Monitor CBC and BMP
If Clinical picture worsens, get plasmapheresis
If BMP worsens, get HD

Delirium in Elderly
Sun downing
Dementia
Sepsis : UTI, Pneumonia and
C.difficle

Secondary Hypertension
Hyperaldosteronism
Hypokalemia with leg cramps
Get hormonal tests ( PAC/ PRA) prior to CT imaging
Spironolactone as medical therapy
CT may show adrenal adenoma
Call surgical consult
If accepted, order adrenalectomy

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