ccs strategy

8/11/2019 CCS Strategy

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Select 'START CASE' button to begin >

You will see the case introduction. Wait! Note on the erasable board:

SettingAge of the patient

Race of the PatientSex of the patient

Then click 'OK' and you will see the initial vital signs. Wait! Note on the erasable board:

Stable or unstable?

Then click 'OK' and you will see the initial history. Wait! Think and write on the erasableboard:

Differential Diagnosis :

AllergiesHabits smoking , alcohol , drugs , etc. Anything worrisome?

Then ask:

Is the patient stable or is it an emergency? A clue to this would be in the history - foremergency cases, you will see only the basic history of present illness and not the detailedhistory (social, past, etc). All other history will be 'unobtainable'.

If unstable, do a EMERGENT physical exam. No emergency case should get a full physicalexam - it's an emergency!!

For the EMERGENT physical, choose the 'general appearance' and the relevant system. Ifneeded, add one or two relevant systems.

After you note the results of the EMERGENT physical, stabilize patient immediately:

Airway Intubation?

Breathing Oxygen mask? Chest tube?

Circulation IV fluids? Dopamine?Drugs Naloxone? Dextrose? Thiamine?IV Access?

Then ask:

Does the patient's condition correlate to the setting?

Emergency or unstable patient in office needs to go to the ER immediately!! Change location

if necessary.

After the patient is stable and in the right setting, proceed to 'Interval/follow-up history' anda more detailed RELEVANT physical exam.


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If the patient is already a stable case in the right setting, proceed straight to the RELEVANT

physical exam.

Then ask:

Is the case limited to one particular system? Like Asthma or MI?

Choose the particular system and a few related systems, based on the most likely diagnosis.

Is the case not limited to one particular system?

Choose a COMPLETE physical exam. This option is available on the top of the physical examchoices. Examples of such cases include Case for Annual Physical Exam, Child Abuse,

Depression, Asymptomatic Hypertensive for Office Management, etc.

Note the significant findings on the physical exam and go back to your erasable paper andrevise your Differential Diagnosis. Strike out those which are less likely and add those are

more likely.

Then keeping the Differential Diagnosis in mind, consider the labs to be done.

When considering labs use this mnemonic:

I B U O P

I Imaging > X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.

B Blood > CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.

U Urine > Urinalysis, Toxicology Screen, Ketones, etc.

OOthers

> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse

Oximetry, Biopsies, etc.

P Pregnancy test > For any female of reproductive age presenting with abdominal or

pelvic symptoms, or trauma.

When ordering labs, consider:

Is this test time-effective/time-consuming? Choose time-effective.

Is this test initial screening/confirmatory? Choose initial screening.

Is this test cheap/expensive? Choose cheap.

Is this test non-invasive/invasive? Choose non-invasive.

Then ask:

Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the

above criteria but will not tell you anything useful.


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Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat

Chloride test for Cystic Fibrosis, etc.

Are the tests in the right order? Example Pulse Oximetry before ABG, CT before SpinalTap, etc.

Order the labs using the Order button.

Then advance clock to the 'Next Available Result'.

Understand the results. Ask:

Is the diagnosis clear or do I need any confirmatory tests?

If diagnosis is clear, start treatment.

If confirmation is needed, order confirmatory tests and then start treatment.

Treatment :

Determine if the patient is in the right setting. If patient is in office and needs to be

admitted, change location to ward. If patient is in ward and is in a serious condition, change

location to ICU.

If case is admitted, order:

IV access (unless IV drugs are not indicated) Type 'IV Access'.

Vital SignsType Vitals and click on 'Every 1,2, 4 or 6 hours' depending on the condition of

patient.

Activity Type 'Bed Rest' and choose 'Complete bed rest' or 'Bed rest with bathroom

privileges' or type restrain and choose 'Restrain patient in bed'.

Diet Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order 'Diet' and you will see the list

of options, choose which is the best for this case.

Tubes NG Tube? Foley's catheter?

Fluids Saline, Ringer, etc. Type 'Fluids' and choose which is the best for this case.

Urine outputType 'Urine Output' and choose frequency. There is no option for

Input/output chart.

Medications :

Stop! Check for allergies on erasable board!

Order standard drugs for this case.


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Decide IV or Oral. Decide bolus or continuous. Decide frequency.

Labs :

Additional labs to confirm diagnosis?

Labs to monitor? Cardiac Monitor? Pulse Oximetry?

Consults :

Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.

Then move clock!

Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12hours/1 day/2 days/1 week.

Do Interval/follow-up history.

Understand the results of the labs.

Then ask:

Has the patient's condition changed significantly?

If yes, change locations.

If the condition has improved, move the patient to the next location in the order ER --> ICU--> Ward --> Office/Home.

If the condition has worsened, move the patient to the next location in the orderHome/Office --> Ward/ER or Ward/ER --> ICU.

If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home):

Stop unnecessary medications and change IV medications to oral.

Discontinue IV fluids.

Remove tubes.Remove IV access.Schedule followup visit in 1 or 2 weeks as relevant.

Patient education or counseling or diet specific and vital to this case. Type 'patienteducation' and 'counsel' and see if anything is relevant to this specific case. Type 'Diet' and

see if anything is relevant to this specific case.

By this time, the 5 minute screen will appear!

Then type 'counsel' and choose the relevant things. You can choose multiple things at atime. See your erasable board for any worrisome habits like alcohol or smoking!

Type 'patient education' and choose the relevant things. You can choose multiple things at a


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time.

Patient education / Counseling options :

Every adult person - Drive with seat belt, Exercise program, No illegal drug use.

Every person taking long-term medications - Medication compliance, Side effects ofmedication.

Every person who takes alcohol - Limit or stop alcohol intake.

Every person who smokes - Smoking cessation.

Every person of reproductive capacity - Safe sex techniques.

Every person with long-term conditions, life-threatening allergies, chronic illnesses - Medic

Alert Bracelet.

Female requesting contraception or practicing unsafe sex - Birth control, Contraception,Safe sex techniques.

Cancer case - Cancer diagnosis.

Asthmatic - Asthma care, medication compliance.

Terminal case - Advance Directive (Family), Advance Directive (Patient) and Living will.

Every post-operative case - Deep breathing and coughing

Diabetic - Diabetic foot care, Home glucose monitoring, Diet.

Learning disorder kid - Educational remediation.

Osteoporosis - Estrogen replacement therapy.

HIV case - HIV support group, safe sex techniques.

Hypothyroidism or endocrine case - Hormone replacement therapy.

Lactose intolerance - Limit cow's milk intake, Diet.

GI bleeding, peptic ulcer case - No aspirin, Sit upright after meals.

Old age, epileptic, vision defects, narcolepsy - No driving.

Anxiety case - Relaxation techniques, Rebreathing into a paper bag.

Violent psychotic case - Restraining order.

Spousal Abuse - Safety plan.


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IV drug use - No illegal drug use, SBE prophylaxis, Safe sex techniques, Stop alcohol,

Smoking cessation.

Pelvic surgery - No intercourse.

STD - Safe sex techniques, Sexual partner needs treatment.

Depression - Suicide contract.

Routine screening : Schedule appropriate screening tests as per age. Type the relevant testand schedule.

Immunizations : For Pediatrics and Geriatrics as relevant. Type 'Vaccine', choose andschedule.

At the end of the 5 minutes:

Type the Final Diagnosis.

You are done!!!

For Kids: Add age appropriate vaxine.

Helmets when Bicycle riding.water temp

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