Archer USMLE Step 3 CCS Workshop - Strategies and Slides. To be used with Archer CCS Video demonstrations/ CCS software practice demonstrations. Learn why CCS is crucial to pass Step 3 exam @ https://archerreview.com/ccs-cases/

1. Archer USMLE Step 3Archer USMLE Step 3
CCS WorkshopCCS Workshop
A component ofA component of
Archer Online USMLE ReviewsArcher Online USMLE Reviews
www.ArcherReview.comwww.ArcherReview.com
USMLE Galaxy, LLC All Rights reserved.USMLE Galaxy, LLC All Rights reserved.
““Dr.Red CCS Workshop” and “Archer CCS Workshop” areDr.Red CCS Workshop” and “Archer CCS Workshop” are
trademarks owned by USMLE Galaxy, LLCtrademarks owned by USMLE Galaxy, LLC
All slides are copyrighted. Monitored by DMCA.All slides are copyrighted. Monitored by DMCA.

2. Webinar – Muting/ UnmutingWebinar – Muting/ Unmuting
For Live workshop attendeesFor Live workshop attendees
WELCOME! We will begin as soon as all the attendeesWELCOME! We will begin as soon as all the attendees
arrive! Thank you!arrive! Thank you!
Some times there is an echo/ noise that gets transmitted inSome times there is an echo/ noise that gets transmitted in
to webinar from the attendee’s surroundings. If you areto webinar from the attendee’s surroundings. If you are
using a computer microphone, there should be a muteusing a computer microphone, there should be a mute
option for you. If there is an echo from your side, you canoption for you. If there is an echo from your side, you can
mute yourself and un-mute when you wish to talk.mute yourself and un-mute when you wish to talk.
If there still is a noise, we will keep you muted. In thatIf there still is a noise, we will keep you muted. In that
case, if you have Questions, please raise your hand socase, if you have Questions, please raise your hand so
that you will be un-muted as soon as possible and yourthat you will be un-muted as soon as possible and your
questions will be answeredquestions will be answered

3. New Changes CCS 2016New Changes CCS 2016
Routine and STAT orders have beenRoutine and STAT orders have been
removed – so, no more confusion with turnremoved – so, no more confusion with turn
around time in different settings.around time in different settings.
All orders are placed as “STAT”All orders are placed as “STAT”
irrespective of Location.irrespective of Location.
Physical exam needs to be selectedPhysical exam needs to be selected
system wise. You can no longer select fullsystem wise. You can no longer select full
physical exam with “one” clickphysical exam with “one” click
No new changes occurred in 2017No new changes occurred in 2017..

4. New Changes To CCSNew Changes To CCS
New changes appeared on CCS component ofNew changes appeared on CCS component of
Step 3 starting Mid-February 2012 and then inStep 3 starting Mid-February 2012 and then in
2016.2016. No changes to software in 2017.No changes to software in 2017.
Changes may mean even more increasedChanges may mean even more increased
importance to CCS in scoring ( this is ourimportance to CCS in scoring ( this is our
opinion). USMLE probably intends to have moreopinion). USMLE probably intends to have more
case scenarios in order to increase thecase scenarios in order to increase the
importance of CCS.importance of CCS.

5. CCS USMLE Step3 - HistoryCCS USMLE Step3 - History
Changes are with regard to “REAL” time and number of cases only.Changes are with regard to “REAL” time and number of cases only.
Simulation time, case approaches, software navigation, locations andSimulation time, case approaches, software navigation, locations and
CCS strategies to score high will remain the same.CCS strategies to score high will remain the same.
Prior to Mid-Feb 2012, examinees are given 9 CCS cases with 25Prior to Mid-Feb 2012, examinees are given 9 CCS cases with 25
minutes REAL time.minutes REAL time.
From Mid-Feb’2012; there have been 12 CCS cases as follows:From Mid-Feb’2012; there have been 12 CCS cases as follows:
8 cases with “Real” time of 20 minutes each.8 cases with “Real” time of 20 minutes each.
4 cases with “Real” time of 10 minutes each.4 cases with “Real” time of 10 minutes each.
The “case-end” screen which used have 5 minutes “REAL” time willThe “case-end” screen which used have 5 minutes “REAL” time will
now have only “2 Minutes” Real time. This will now be called as “ 2now 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 “minute screen” in our workshops instead of referring it as “5 minute “
screen .screen .
As discussed in “Archer CCS strategies”, all important guidelines to beAs discussed in “Archer CCS strategies”, all important guidelines to be
implemented on case-end screen previously referred to as “5-Minimplemented on case-end screen previously referred to as “5-Min
screen orders” are to be done on 2-min screen.screen orders” are to be done on 2-min screen.

6. CCS TipsCCS Tips
Note the setting (location) of the patient encounter. The settingNote the setting (location) of the patient encounter. The setting
helps you decide on the aggressiveness of your treatment ordershelps you decide on the aggressiveness of your treatment orders
and whether to send the patient home. It also gives a clue to theand whether to send the patient home. It also gives a clue to the
medical diagnosis.medical diagnosis.
In the setting of ER, do not waste time if vitals are unstable. Do notIn the setting of ER, do not waste time if vitals are unstable. Do not
discharge the patient without confirmed diagnosis or with-outdischarge the patient without confirmed diagnosis or with-out
stabilizing him. If you are not sure of the medical diagnosis, admitstabilizing him. If you are not sure of the medical diagnosis, admit
the patient and work him up. You can always discharge him from thethe patient and work him up. You can always discharge him from the
hospital, the next day.hospital, the next day.
Write down the age, sex, chief complaint, and allergies of the patientWrite down the age, sex, chief complaint, and allergies of the patient
on the writing sheet provided at the exam. This will help you saveon the writing sheet provided at the exam. This will help you save
time when considering medical differential diagnosis.time when considering medical differential diagnosis.
If you did not write it down the important points in History, do notIf you did not write it down the important points in History, do not
panic. You can always access it from the Order sheet button. Clickpanic. You can always access it from the Order sheet button. Click
on “Write order” button and then select “Progress notes”. Youron “Write order” button and then select “Progress notes”. Your
patient’s initial H & P as well as updates are stored under thispatient’s initial H & P as well as updates are stored under this
section.section.

7. CCS TipsCCS Tips
Two “Times” on the softwareTwo “Times” on the software
““Real” time – the time on the bottom of the screenReal” time – the time on the bottom of the screen
on the right side.on the right side.
““Simulated” time – the time on the bottom of theSimulated” time – the time on the bottom of the
screen on the left sidescreen on the left side

8. New Changes To CCS since 2012New Changes To CCS since 2012
TIMES Remained same since 2012. NoTIMES Remained same since 2012. No
changes in 2017 with regard to these times.changes in 2017 with regard to these times.
REAL TIMES:REAL TIMES:
20 minute cases :20 minute cases :
18 minutes for “active” screen and 2 minutes for18 minutes for “active” screen and 2 minutes for
“Case-end” screen.“Case-end” screen.
10 minute cases :10 minute cases :
8 minutes for “active” screen and 2 minutes for8 minutes for “active” screen and 2 minutes for
““Case-end” screenCase-end” screen
• You need to be fast in navigating the software and you need to prioritize yourYou 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 yourselforders! You need lot more practice with the software to thoroughly orient yourself
!!

9. ““RealReal”” TimeTime
““Real” time – the time on the bottom of the screen on the right side.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 yourYou 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 minutescases will have 18 minutes real time and 4 of your cases will have 8 minutes
real time.real time.
Real time is not scored. However, if you run out of the real time of - your “2”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 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 themminute 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 orbefore 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”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 clockand 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 ofquickly 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 optimallyyour “18” minutes active “real” time and will not be able to optimally
complete the case.complete the case.

10. Case end (2-minute screen)Case end (2-minute screen)
YouYou cannotcannot do certain steps on 2-Minute screendo certain steps on 2-Minute screen
you cannot change patient locationyou cannot change patient location
you cannot advance the clockyou cannot advance the clock
you cannot discharge the patientyou cannot discharge the patient
you cannot obtain resultsyou cannot obtain results
you cannot assess the patient lateryou cannot assess the patient later
YouYou cancan do certain important steps on 2 Minute screen.do certain important steps on 2 Minute screen.
Prioritize your 2-minute screen orders in the following order.Prioritize your 2-minute screen orders in the following order.
AddAdd any needed orders to be done “NOW”any needed orders to be done “NOW”
DiscontinueDiscontinue any unnecessary orders that are appropriate “NOW”.any unnecessary orders that are appropriate “NOW”.
Understand the meaning of word “NOW”.Understand the meaning of word “NOW”. The word “NOW” refers to thatThe word “NOW” refers to that
“simulated time” at that point in patient’s life. ( Please check the“simulated time” at that point in patient’s life. ( Please check the
“simulated” time before you discontinue any crucial orders. You do not“simulated” time before you discontinue any crucial orders. You do not
want to discontinue any stabilizing orders on day 1 or if your patient haswant to discontinue any stabilizing orders on day 1 or if your patient has
just arrived).just arrived).
AddAdd any tests or orders or follow-up monitoringany tests or orders or follow-up monitoring relevantrelevant to the patient’sto the patient’s
current presentation to be done in “current presentation to be done in “LATERLATER” . “LATER” refers to future” . “LATER” refers to future
simulated time which you can select using the calendar.simulated time which you can select using the calendar.
You can order all “Counseling” orders “at once”. Choose the timing asYou can order all “Counseling” orders “at once”. Choose the timing as
“Now” – “non invasive” steps like “counseling” do not bring your score“Now” – “non invasive” steps like “counseling” do not bring your score
down. If anything, you might get credited for some counseling orders.down. If anything, you might get credited for some counseling orders.
However, prioritize these counseling orders .However, prioritize these counseling orders . You only have two minutesYou only have two minutes ––
if you are running out of time, do not bother to do “routine” counselling . Asif you are running out of time, do not bother to do “routine” counselling . As
long as you ordered “case-specific” counseling , you are good!long as you ordered “case-specific” counseling , you are good!
Schedule “Screening” tests for a “Later” dateSchedule “Screening” tests for a “Later” date

11. ““Simulated” TimeSimulated” Time
The time that is scoredThe time that is scored
It is the time since the patient arrived in the “ER” or the time sinceIt 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.you first saw your patient in the “office” on a CCS case.
This is the time that is most crucial in ER cases. For mostThis is the time that is most crucial in ER cases. For most
unstable cases, you are expected to complete life-saving stepsunstable cases, you are expected to complete life-saving steps
or therapies within first 1 hour of SIMULATED time.or therapies within first 1 hour of SIMULATED time.
In the ER cases, keep the simulated time low i.e; try to complete theIn the ER cases, keep the simulated time low i.e; try to complete the
“Life saving” steps or important diagnostic tests in the least“Life saving” steps or important diagnostic tests in the least
simulated time possible.simulated time possible. This is highly scoredThis is highly scored..
Simulated time will change only when :Simulated time will change only when :
You advance the clockYou advance the clock
Do a physicalDo a physical
Do a “Interval” historyDo a “Interval” history
If you order the tests and wait, nothing will show up. Simulated timeIf you order the tests and wait, nothing will show up. Simulated time
will not change but your real time will run.will not change but your real time will run.
Advance the clock to make things happen. However, check theAdvance the clock to make things happen. However, check the
“report” time of your orders on the order sheet, know your goals,“report” time of your orders on the order sheet, know your goals,
know your monitoring parameters and what you are waiting for andknow your monitoring parameters and what you are waiting for and
then advance the clock to that “particular” report time.then advance the clock to that “particular” report time.
Sometimes, you can advance the clock in a way that can make you look verySometimes, 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 waitingefficient. Move the “Simulated time” to the “Report” time that you are waiting
for by “completing a previously unfinished physical” or by “Interval/ follow up”for by “completing a previously unfinished physical” or by “Interval/ follow up”
history. Interval history will advance the clock by 2 minutes.history. Interval history will advance the clock by 2 minutes.

12. Components that are scoredComponents that are scored
Several of your approaches may be scored . YourSeveral of your approaches may be scored . Your
approaches will be scored as “optimal”, “sub-optimal” orapproaches will be scored as “optimal”, “sub-optimal” or
“poor”. If have satisfied most of the “optimal” steps and“poor”. If have satisfied most of the “optimal” steps and
did not involve in any “unnecessary invasive or harmful”did not involve in any “unnecessary invasive or harmful”
steps, you will receive > 90% of the Score.steps, you will receive > 90% of the Score.

13. Components that are scoredComponents that are scored Most important areas that are scored:Most important areas that are scored:
 Don’t forget these! : DDon’t forget these! : Danceance LLikeike TThehe MMovieovie SStars (tars ( DLTMS)DLTMS)
DiagnosisDiagnosis ( history and physical exam, appropriate diagnostic tests. “Focused” physical only( history and physical exam, appropriate diagnostic tests. “Focused” physical only
when patients are unstable)when patients are unstable)
LocationLocation (( Location of your treatment and evaluation. Unstable cases should be sent to ER asLocation 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 testssoon 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, “CHANGEin 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. )LOCATION”. If ICU criteria are met, send to ICU. If not met, send to ward. )
TimingTiming ( Keeping the “Simulated” time low in ER cases or unstable cases i.e; ordering “optimal”( 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)steps within usually, first “one hour” of patient simulated time)
SequencingSequencing ( Sequencing your orders . For example, stabilizing a patient( Sequencing your orders . For example, stabilizing a patient firstfirst andand thenthen orderingordering
an imaging study in aortic dissectionan imaging study in aortic dissection beforebefore obtaining a surgery consult. This is just an example!obtaining a surgery consult. This is just an example!
Sequencing will be demonstrated more in our practice cases. Correct “Sequencing” is extremelySequencing will be demonstrated more in our practice cases. Correct “Sequencing” is extremely
important )important )
MonitoringMonitoring ( Once you treat a patient, MONITOR!!( Once you treat a patient, MONITOR!! That’s your JOBThat’s your JOB!. Monitoring parameters!. Monitoring parameters
can be as simple as doing a repeat focused physical or labs( chest exam in “Asthma” cases aftercan 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/deliriumtreatment, 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 drugcases , 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” andadverse effects or drug efficiency in some office cases …For example: getting a “lipid panel” and
“LFT” s at an“LFT” s at an appropriateappropriate laterlater date after starting STATINS in an office case. Another example isdate after starting STATINS in an office case. Another example is
getting “LFTs” at a later date after starting Methotrexate in a Rheumatoid arthritis case ( 30daysgetting “LFTs” at a later date after starting Methotrexate in a Rheumatoid arthritis case ( 30days
after initiation) ) – Followafter initiation) ) – Follow MONITORING GUIDELINESMONITORING GUIDELINES

14. ER SettingER Setting
Vitals firstVitals first
This is the screen where you make up your mind regarding theThis is the screen where you make up your mind regarding the
“UNSTABLE” scenario. Define Shock or Respiratory failure.“UNSTABLE” scenario. Define Shock or Respiratory failure.
Tachycardia per se, is not usually an unstable vital unless it isTachycardia per se, is not usually an unstable vital unless it is
associated with irregular rhythm ( you will know on physical) or Shock.associated with irregular rhythm ( you will know on physical) or Shock.
A high temperature should remind you of the possibility of “Sepsis”,A high temperature should remind you of the possibility of “Sepsis”,
“Infection” or “Heat Stroke”. Remember that some non-infectious“Infection” or “Heat Stroke”. Remember that some non-infectious
conditions like “Drug fever”, “Malignancy” or “Pulmonary embolism”conditions like “Drug fever”, “Malignancy” or “Pulmonary embolism”
can also have fever. A high temperature may not always becan also have fever. A high temperature may not always be
“INFECTION” ( know the definition of “SIRS” and “Sepsis”). A high“INFECTION” ( know the definition of “SIRS” and “Sepsis”). A high
temperature is not usually an “UNSTABLE” vital unless there is atemperature is not usually an “UNSTABLE” vital unless there is a
suspicion of “Heat stroke”suspicion of “Heat stroke”
PertinentPertinent physical examphysical exam
Do not waste time doing complete physical. ( DoingDo not waste time doing complete physical. ( Doing
complete physical is regarded as “poor management” incomplete physical is regarded as “poor management” in
unstable cases)unstable cases)
Fast treatment – first stabilize.Fast treatment – first stabilize. After stabilizing and afterAfter stabilizing and after
treating adequatelytreating adequately, you can proceed with, you can proceed with completecomplete
physical ( do not forget it!)physical ( do not forget it!)

15. ShockShock
Shock – defined as SBP < 90 or MAP < 65Shock – defined as SBP < 90 or MAP < 65
Different types of ShockDifferent types of Shock
Hypovolemic shockHypovolemic shock
Distributive shockDistributive shock
Septic ShockSeptic Shock
Anaphylactic ShockAnaphylactic Shock
Opiod OverdoseOpiod Overdose
Cardiogenic ShockCardiogenic Shock
Right Ventricular MIRight Ventricular MI
Left Ventricular MILeft Ventricular MI
Cardiac tamponadeCardiac tamponade
VSD/ Papilalry muscle rupture – post MIVSD/ Papilalry muscle rupture – post MI
Obstructive ShockObstructive Shock
Tension PneumothoraxTension Pneumothorax
Pulmonary EmbolismPulmonary Embolism
Air EmbolismAir Embolism
Cardiac TamponadeCardiac Tamponade

16. Initial Step in ShockInitial Step in Shock
Suspected causeSuspected cause
of Shockof Shock
History cluesHistory clues Physical cluesPhysical clues Initial therapyInitial therapy
HypovolemiaHypovolemia -MVA with bleedingMVA with bleeding
-DehydrationDehydration
-DiarrheaDiarrhea
-VomitingVomiting
-Vaginal bleedingVaginal bleeding
Remember, Strong clues from history & vitals reveal “Shock”Remember, Strong clues from history & vitals reveal “Shock” 
Proceed to order sheetProceed to order sheet
No clues from historyNo clues from history  do 2 minute physical, to evaluate thedo 2 minute physical, to evaluate the
cause of shock ( add abdomen to focused physical if historycause of shock ( add abdomen to focused physical if history
suggestive) – doing 2 minute physical will determine your nextsuggestive) – doing 2 minute physical will determine your next
life saving step herelife saving step here
-Orthostatic hypotensionOrthostatic hypotension
-( you have to order this( you have to order this
on the screen)on the screen)
-Dry oral mucosaDry oral mucosa
-TachycardiaTachycardia
-Stool guaic positiveStool guaic positive
-Gross bleedingGross bleeding
-Abdominal signs suggestingAbdominal signs suggesting
bleeding or perforation orbleeding or perforation or
peritonitisperitonitis
-Heavy Vaginal bleedingHeavy Vaginal bleeding
IV Fluid – NS bolusesIV Fluid – NS boluses
If suspecting hemorrhagicIf suspecting hemorrhagic
shock – order Type and crossshock – order Type and cross
match and blood transfusionmatch and blood transfusion
right away ( Don’t wait for CBC)right away ( Don’t wait for CBC)
DistributiveDistributive
shockshock
- Clues to anaphylaxis- Clues to anaphylaxis
-Clues to infection ( fever on “vitals” screen)Clues to infection ( fever on “vitals” screen)
-Clues to drug useClues to drug use
-Fever may point to septic shockFever may point to septic shock
-Wheals - anaphylaxisWheals - anaphylaxis
-Always, IV Normal saline Stat (Always, IV Normal saline Stat (
fill up the SVR)fill up the SVR)
- Epinephrine if anaphylaxisEpinephrine if anaphylaxis
-Antibiotics if SespsisAntibiotics if Sespsis
ObstructiveObstructive
ShockShock
- Chest pain/ sob – can indicate tension pneumothorax, cardiac- Chest pain/ sob – can indicate tension pneumothorax, cardiac
tamponade or PE – history clues are not very suggestivetamponade or PE – history clues are not very suggestive 
proceed to 2 minute physicalproceed to 2 minute physical
2 minute physical ( RS, CVS)2 minute physical ( RS, CVS)
-Reveals absent breath soundsReveals absent breath sounds
Tension pneumothoraxTension pneumothorax
-Reveals pulsus paradoxus, JVDReveals pulsus paradoxus, JVD
–– Cardiac tamponadeCardiac tamponade
-Reveals normal physical +Reveals normal physical +
-historical clueshistorical clues  suspect PEsuspect PE
After 2 minuteAfter 2 minute
Physical, order life saving stepPhysical, order life saving step
Pneumo – chest tubePneumo – chest tube
Tamponade pericardiocentesisTamponade pericardiocentesis
& then window& then window
PE – Spiral ct and then tpa,PE – Spiral ct and then tpa,
hold heparinhold heparin
Air – trendelenberg positionAir – trendelenberg position
CardiogenicCardiogenic
shockshock
Chestpain, sobChestpain, sob 2 minute physical – make sure2 minute physical – make sure
chest is clear. If raleschest is clear. If rales  LeftLeft
ventricular MI. Then get EKGventricular MI. Then get EKG
If chest clearIf chest clear  IV Fluids. IfIV Fluids. If
ralesrales  hold IV fluids, GEThold IV fluids, GET
EKG, then IABC and cardiacEKG, then IABC and cardiac
cath. Order other MIcath. Order other MI
managementmanagement

17. Respiratory FailureRespiratory Failure
Respiratory Rate > 30 – unstable, tachypneaRespiratory Rate > 30 – unstable, tachypnea
Address it STATAddress it STAT
If you have a clue, go straight to order sheet ( hx of Asthma, COPD,If you have a clue, go straight to order sheet ( hx of Asthma, COPD,
PE clues)PE clues)
If no clues from history or associated with chest painIf no clues from history or associated with chest pain  do 2 minutedo 2 minute
physical ( R.S, CVS) eg : D/D includes Tension pneumothorax,physical ( R.S, CVS) eg : D/D includes Tension pneumothorax,
pulmonary edema, MI with pulmonary edema, PE. By doing a 2pulmonary edema, MI with pulmonary edema, PE. By doing a 2
minute exam, you can order the “stabilizing and life saving step”minute exam, you can order the “stabilizing and life saving step”
within 2 minutes of “Simulated” time . At 2 minutes of simulatedwithin 2 minutes of “Simulated” time . At 2 minutes of simulated
time:time:
Chest tube if pneumothorax ( don not wait for CXR)Chest tube if pneumothorax ( don not wait for CXR)
Pericardiocentesis if cardiac tamponadePericardiocentesis if cardiac tamponade
CT chest and tpA if highly suspected PECT chest and tpA if highly suspected PE
Morphine and furosemide if Acute Pulmonary EdemaMorphine and furosemide if Acute Pulmonary Edema
Nebulizations ( Albuterol + Ipratropium) and corticosteroids ifNebulizations ( Albuterol + Ipratropium) and corticosteroids if
asthma/ COPD exacerbation ( wide spread wheezes, accessoryasthma/ COPD exacerbation ( wide spread wheezes, accessory
muscle use)muscle use)
Get ABGs in all cases of respiratory failure ( other placeGet ABGs in all cases of respiratory failure ( other place
where ABGs are needed is when you see low metabolicwhere ABGs are needed is when you see low metabolic

18. SepsisSepsis
Know the definition of “SIRS” – “Systemic Inflammatory ResponseKnow the definition of “SIRS” – “Systemic Inflammatory Response
Syndrome”. “SIRS” is indicated by at least two of the following:Syndrome”. “SIRS” is indicated by at least two of the following:
Fever or hypothermia—temperature 38°C or higher or 36°C or lowerFever or hypothermia—temperature 38°C or higher or 36°C or lower
Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”)Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”)
Tachycardia > 100 beats/ minTachycardia > 100 beats/ min
White blood cell count – leucocytosis (12,000 cells/mm3 or more) orWhite blood cell count – leucocytosis (12,000 cells/mm3 or more) or
leucopenia ( 4,000 cells/mm3 or less, or greater than 10% bands onleucopenia ( 4,000 cells/mm3 or less, or greater than 10% bands on
differential count)differential count)
““SIRS” is not always due to infection. “SIRS” can be due to :SIRS” is not always due to infection. “SIRS” can be due to :
InfectionInfection
BurnsBurns
PancreatitisPancreatitis
TraumaTrauma
Pulmonary embolismPulmonary embolism
VasculitisVasculitis
Sepsis : To diagnose “Sepsis”, there should be a “presumed” orSepsis : To diagnose “Sepsis”, there should be a “presumed” or
“known”“known” site of infectionsite of infection + evidence of a systemic inflammatory+ evidence of a systemic inflammatory
response ( SIRS)response ( SIRS)

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

20. Septic ShockSeptic Shock
Suspicion or evidence of sepsis + ShockSuspicion or evidence of sepsis + Shock
Follow quick sepsis guidelinesFollow quick sepsis guidelines
ABCABC
OxygenOxygen
Continuos B.P monitoringContinuos B.P monitoring
Pan culturesPan cultures
IV FLUIDS – NS – MOST IMPORTANTIV FLUIDS – NS – MOST IMPORTANT
If BP does not improve, add a pressor. If your patient isIf BP does not improve, add a pressor. If your patient is
tachycardic, choose Nor-epinephrine. If your patient has atachycardic, choose Nor-epinephrine. If your patient has a
low output state, use Dopamine.low output state, use Dopamine.
Early antibiotics to address the “presumed” sourceEarly antibiotics to address the “presumed” source

21. ““Presumed” or “Known” site ofPresumed” or “Known” site of
infectioninfection
Possible “Bugs”Possible “Bugs” Emperical therapyEmperical therapy
Community acquired pneumoniaCommunity acquired pneumonia S.pneumoniae, Legionella, mycoplasma,S.pneumoniae, Legionella, mycoplasma,
H.influenzaeH.influenzae
Third generation cephalosporin +Third generation cephalosporin +
macrolide or Newer Quinolonemacrolide or Newer Quinolone
Early Hospital Acquired Pneumonia ( < 5Early Hospital Acquired Pneumonia ( < 5
days)days)
Gram negative rods – non resistantGram negative rods – non resistant
( e.coli, proteus, klebsiella),( e.coli, proteus, klebsiella),
S.pneumonia, H.influenzae, legionellaS.pneumonia, H.influenzae, legionella
PIP/TAZO, Unasyn, Cefepime or newerPIP/TAZO, Unasyn, Cefepime or newer
quinolonequinolone
Late Hospital Acquired Pneumonia ( >Late Hospital Acquired Pneumonia ( >
5days)5days)
Resistant gram –ves (ESBL),Resistant gram –ves (ESBL),
Pseudomonas, MRSAPseudomonas, MRSA
Use anti-pseudomonal drugs –Use anti-pseudomonal drugs –
PIP/TAZO + quinolone, Cefepime,PIP/TAZO + quinolone, Cefepime,
Imipenem, Vancomycin (if MRSAImipenem, Vancomycin (if MRSA
suspected)suspected)
Intra abdominal infections ( diverticulitis)Intra abdominal infections ( diverticulitis) Enteric gram –ve rods ( E.coli),Enteric gram –ve rods ( E.coli),
Anerobes (B.fragilis)Anerobes (B.fragilis)
Use good anerobic coverage :Use good anerobic coverage :
Cipro+flagyl, Pip/tazo, Ertapenem,Cipro+flagyl, Pip/tazo, Ertapenem,
Imipenem. Do not use cephalosporinImipenem. Do not use cephalosporin
alone ( add metronidazole if using it)alone ( add metronidazole if using it)
Urinary tract infectionsUrinary tract infections E.coli, proteusE.coli, proteus
EnterococciEnterococci
Quinolone, ceftriaxone, extendedQuinolone, ceftriaxone, extended
spectrum beta lactums,spectrum beta lactums, if enterococci isif enterococci is
presentpresent  use ampicillin or vancomycinuse ampicillin or vancomycin
MeningitisMeningitis S.pneumonia, H.influenzae,S.pneumonia, H.influenzae,
N.meningitidis, E.coli. In ages < 1monthN.meningitidis, E.coli. In ages < 1month
or > 50 years -Listeriaor > 50 years -Listeria
Vanco+Ceftriaxone. If listeria suspected,Vanco+Ceftriaxone. If listeria suspected,
add Ampicillin. Give Dexametasone prioradd Ampicillin. Give Dexametasone prior
to antibioticsto antibiotics
Pseudomembranous colitis/ C.DifficlePseudomembranous colitis/ C.Difficle
DiarrheaDiarrhea
c.difficlec.difficle Metronidazole p.o. If resistant, use vancoMetronidazole p.o. If resistant, use vanco
p.o ( do not use I.V vanco – notp.o ( do not use I.V vanco – not
effective)effective)
Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS caseSimple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case

22. ER Setting – A simple approachER Setting – A simple approach
Presenting IssuePresenting Issue Next Step on CCSNext Step on CCS
Vitals” are very unstable + you, absolutely, have no clueVitals” are very unstable + you, absolutely, have no clue
about the diagnosis from the historyabout the diagnosis from the history
Go to “physical screen “ – do a very focused physical ( 2Go to “physical screen “ – do a very focused physical ( 2
minutes – Chest and Cardiovascular. Considerminutes – Chest and Cardiovascular. Consider
“abdomen” only if history revealed abdominal pain or“abdomen” only if history revealed abdominal pain or
trauma)trauma)  Proceed to order sheet (Remember that whenProceed to order sheet (Remember that when
you have no clue from the history, a “Life” saving step foryou have no clue from the history, a “Life” saving step for
a severely unstable vital may not be identified until youa severely unstable vital may not be identified until you
do the “2-Minute” ( Chest, Cardiovascular) physical).do the “2-Minute” ( Chest, Cardiovascular) physical).
Remember that if this step is done early ( less “Simulated”Remember that if this step is done early ( less “Simulated”
time), you will get maximum scoretime), you will get maximum score
““Vitals” are “UNSTABLE” ( Shock or respiratory failure) +Vitals” are “UNSTABLE” ( Shock or respiratory failure) +
you have a clue about the diagnosis from the historyyou have a clue about the diagnosis from the history
Proceed to “Order sheet” and try to stabilize. WriteProceed to “Order sheet” and try to stabilize. Write
“Stabilizing” orders, “Basic” orders, “Symptom” relieving“Stabilizing” orders, “Basic” orders, “Symptom” relieving
orders. Write “Specific” diagnostic tests and “Specific”orders. Write “Specific” diagnostic tests and “Specific”
treatment since you already have a clue about thetreatment since you already have a clue about the
diagnosis from the history ( Some examples: Anaphylacticdiagnosis from the history ( Some examples: Anaphylactic
shock, Hypovolemic shock from MVA , strong clues ofshock, Hypovolemic shock from MVA , strong clues of
“PE” in the history )“PE” in the history )
““Vitals” are “Stable” no “ Pain”Vitals” are “Stable” no “ Pain” Full physical and then go to “order” sheetFull physical and then go to “order” sheet
“ ““ “Vitals” stable but History reveals severe “pain”Vitals” stable but History reveals severe “pain” Address pain first and then come back to physical screenAddress pain first and then come back to physical screen
( except in abdominal pain – do abdomen exam first and( except in abdominal pain – do abdomen exam first and
then address pain)then address pain)

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

24. PainPain
Consider “Pain” as theConsider “Pain” as the fifth vitalfifth vital
Addressing severe pain immediately isAddressing severe pain immediately is
extremely important..
If your patient is in severe pain and vitals areIf your patient is in severe pain and vitals are
stable, go to order sheetstable, go to order sheet firstfirst, give a pain, give a pain
medicationmedication firstfirst and then go back to doand then go back to do
“focused” physical.“focused” physical.
Most ER pains, can use Morphine if severeMost ER pains, can use Morphine if severe
Pain in officePain in office  follow “analgesic ladder”follow “analgesic ladder”

25. ER SettingER Setting
Admission if required – move patient toAdmission if required – move patient to
ward or ICUward or ICU
Criteria for admission to the ICU – shock,Criteria for admission to the ICU – shock,
resp failure, DKA, Acute MI, Refractoryresp failure, DKA, Acute MI, Refractory
electrolyte issues, Acute deliriumelectrolyte issues, Acute delirium

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

27. Basic set of ER ordersBasic set of ER orders
VitalsVitals
Oxy ( pulse ox, oxygen)Oxy ( pulse ox, oxygen)
IVA ( IV Access)IVA ( IV Access)
EKGEKG
Cardiac monitorCardiac monitor
UrinalysisUrinalysis
BMP ( CMP takes 2 hours, BMP 30 minutess. If you needBMP ( CMP takes 2 hours, BMP 30 minutess. If you need
LFTs order them separately rather than ordering a CMP)LFTs order them separately rather than ordering a CMP)
CBCCBC
Checking interval history often is a type of “monitoring”Checking interval history often is a type of “monitoring”
Don’t enter blood cultures and antibiotics together. BloodDon’t enter blood cultures and antibiotics together. Blood
cx first, advance clock by 1 min and then antibiotics. This iscx first, advance clock by 1 min and then antibiotics. This is
very important in case of Infective Endocarditis wherevery important in case of Infective Endocarditis where
blood cultures x 3 must be obtained 30 minutes apartblood cultures x 3 must be obtained 30 minutes apart
before starting antibiotics –before starting antibiotics – cultures here dictatecultures here dictate
management decisions further in that casemanagement decisions further in that case

28. Indications for ICU admissionIndications for ICU admission
ShockShock
Respiratory failureRespiratory failure
Post –op 24 hours in some casesPost –op 24 hours in some cases
Post MIPost MI
DKA/ Refractory electrolyte abnormalitiesDKA/ Refractory electrolyte abnormalities
Acute delirium/ altered mental statusAcute delirium/ altered mental status

29. General ICU OrdersGeneral ICU Orders
Elevate head end of the bed ( to preventElevate head end of the bed ( to prevent
aspiration pneumonia in ICU setting)aspiration pneumonia in ICU setting)
DVT Prophylaxis ( order compression stockingsDVT Prophylaxis ( order compression stockings
or TED stockings)or TED stockings)
Stress ulcer prophylaxis ( orders PPI such asStress ulcer prophylaxis ( orders PPI such as
pantoprazole)pantoprazole)
Activity ( Bed rest, ambulate in room)Activity ( Bed rest, ambulate in room)
Output monitoring ( Foley if obstruction or ifOutput monitoring ( Foley if obstruction or if
unresponsive/ delirium)unresponsive/ delirium)
Diet ( NPO, Diet or NG Tube if disoriented)Diet ( NPO, Diet or NG Tube if disoriented)
Neurochecks if disorientedNeurochecks if disoriented
Suction airway if comatose or disorientedSuction airway if comatose or disoriented

30. Time required and Invasiveness –Time required and Invasiveness –
tests in ERtests in ER
TIMING & INVASIONTIMING & INVASION
You need have an idea about how long it takes for certainYou need have an idea about how long it takes for certain
tests and invasiveness of certain diagnostic teststests and invasiveness of certain diagnostic tests
Checking report time by putting in certain orders givesChecking report time by putting in certain orders gives
you an idea how long it takes for the test results to comeyou an idea how long it takes for the test results to come
backback
V/Q scan vs. CT angiogram in Unstable PEV/Q scan vs. CT angiogram in Unstable PE
BMP vs. CMP in DKABMP vs. CMP in DKA
CT chest vs. TEE in aortic dissection ( both take sameCT chest vs. TEE in aortic dissection ( both take same
time. Though TEE is more specific, CT scan is leasttime. Though TEE is more specific, CT scan is least
invasive)invasive)
ABI with arterial doppler vs. Angiogram for PADABI with arterial doppler vs. Angiogram for PAD

31. Unresponsiveness in ERUnresponsiveness in ER
Get basic stuff quickLY :Get basic stuff quickLY :
- CHECK VITALS FIRSTCHECK VITALS FIRST
- ABCs – suction airwayABCs – suction airway
- Do not intubate right away with out knowing the possible cause of comaDo not intubate right away with out knowing the possible cause of coma
( for example, if finger stick shows low glucose – patient might respond( for example, if finger stick shows low glucose – patient might respond
right away after giving dextrose). Look and exclude rapidly reversibleright away after giving dextrose). Look and exclude rapidly reversible
causes of coma by using history, physical and lab testscauses of coma by using history, physical and lab tests
( hypoglycemia, opiod overdose, BZD overdose, hepatic( hypoglycemia, opiod overdose, BZD overdose, hepatic
encephalopathy etc) before you prophylactically intubate for airwayencephalopathy etc) before you prophylactically intubate for airway
protection in comaprotection in coma
- fingerstick glucose stat (Accucheck),- fingerstick glucose stat (Accucheck),
- naloxone given if opiates are suspected (Pupils)- naloxone given if opiates are suspected (Pupils)
- thiamine added to IV fluids if alcoholic.thiamine added to IV fluids if alcoholic.
Not all comatose patients need this cocktail.Not all comatose patients need this cocktail. Check theCheck the
history – you may find clueshistory – you may find clues ( heat stroke, fever with( heat stroke, fever with
delirium, motor weakness with delirium, finger stickdelirium, motor weakness with delirium, finger stick
glucose very high with delirium as in DKA or HONK)glucose very high with delirium as in DKA or HONK)

32. Obtaining ConsultsObtaining ConsultsWhether in ER setting or office setting there are some issues where youWhether in ER setting or office setting there are some issues where you
must get consultsmust get consults
certain procedures – surgeries, tube thoracostomy, thoracotomy, depression, suicide attempt,certain procedures – surgeries, tube thoracostomy, thoracotomy, depression, suicide attempt,
drug overdose, cardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eyedrug overdose, cardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eye
procedures, ENT stuff, EGD, Colonoscopy – get appropriate consultsprocedures, ENT stuff, EGD, Colonoscopy – get appropriate consults
for expert opinionfor expert opinion
You will be credited for asking necessary consultsYou will be credited for asking necessary consults
You can type “Obtain consent for procedure” to get consent.You can type “Obtain consent for procedure” to get consent.
If you are obtaining a surgical consult, get the consult first . Then,If you are obtaining a surgical consult, get the consult first . Then,
advance the clock to the “report” time of consult. If the patient isadvance the clock to the “report” time of consult. If the patient is
accepted for procedure now orderaccepted for procedure now order ::
NPONPO
Obtain consent for procedureObtain consent for procedure
IV accessIV access
Type and crossmatchType and crossmatch
PT, PTTPT, PTT
Name of the procedure itself (Name of the procedure itself ( eg: hysterectomy, adrenalectomy e.t.c)eg: hysterectomy, adrenalectomy e.t.c)
Surgeon will always accept the patient for surgery if the criteria forSurgeon will always accept the patient for surgery if the criteria for
surgery are met. If the surgeon did not accept, check carefully if yousurgery 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 thehave 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 notcriteria for surgery if surgery is indicated. If you feel surgeon is not
accepting even after you have completely met the criteria, it is possibleaccepting even after you have completely met the criteria, it is possible
that surgery is not the treatment of choice at that time in the softwarethat surgery is not the treatment of choice at that time in the software
algorithmalgorithm  do not order surgical procedure if the patient is not accepteddo not order surgical procedure if the patient is not accepted
by the surgeonby the surgeon!!

33. Using keywordsUsing keywords
OxyOxy
CouCou
StopStop
AvoidAvoid
DietDiet
FluidsFluids
AdviseAdvise
Vacci etcVacci etc

34. Advancing clockAdvancing clock
Advance only after putting appropriateAdvance only after putting appropriate
ordersorders
If you do not advance you will use up yourIf you do not advance you will use up your
real time without nothing happening withreal time without nothing happening with
the patientthe patient
If you do not advance , it means you haveIf you do not advance , it means you have
not implemented the orders you wrotenot implemented the orders you wrote
Advance clock to get results when neededAdvance clock to get results when needed

35. Before advancing clock!Before advancing clock!
Think twice is there anything else that needs toThink twice is there anything else that needs to
be done, Esply true for ER Casesbe done, Esply true for ER Cases
If you already stabilized the patient but had doneIf you already stabilized the patient but had done
only focused physical at presentation in ER, youonly focused physical at presentation in ER, you
may use this waiting time to complete your othermay use this waiting time to complete your other
relevant physical - this is the time to do it – whilerelevant physical - this is the time to do it – while
awaiting the lab results, imaging studies etc – doawaiting the lab results, imaging studies etc – do
not advance the clock just to get results unlessnot advance the clock just to get results unless
you have nothing else left to do.you have nothing else left to do.
Eg: you order a CBC – Let us say order time isEg: you order a CBC – Let us say order time is
8:40 and report time is 9:20 – do an interval hx8:40 and report time is 9:20 – do an interval hx
or a previously unfinished physical in the meanor a previously unfinished physical in the mean
time that will automatically advance the clocktime that will automatically advance the clock
further.further.

36. Stop Clock FunctionStop Clock FunctionStop the clock function is a critical step.Stop the clock function is a critical step.
When you start advancing the clock to a future time, several results of the tests youWhen 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 youordered 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.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 -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"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 addressclock 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 canthat 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.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:The following is very important and can affect your score in Office Cases:
• ““Stop the clock" after the result is very important in office cases scenarios as well. When the patient is atStop the clock" after the result 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"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 orand 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 resultscommon 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 ivare 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 thetreatments 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.clock" and change the patient location to "ER" and then give further iv treatments.  WhenWhen critical patientcritical patient
“updates” or results mandate immediate attention, advancing the clock without addressing those updates“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 regardwould 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).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 mustIn office cases, when you press "Stop the clock" button previous appointment will be cancelled. You must
reschedule the appointment after each time you stop the clock. This memory of previously scheduledreschedule 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 anappointment 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 mustimportant result and such a decision may lead you to pre-pone or post-pone the appointment. So, you must

37. Using control buttonUsing control button
You can select multiple orders by usingYou can select multiple orders by using
control button so that u don’t waste muchcontrol button so that u don’t waste much
timetime

38. Diet ordersDiet orders
Order appropriate diet for admissionsOrder appropriate diet for admissions
Type “diet” to select what you need in yourType “diet” to select what you need in your
casecase

39. Follow up & Interval HxFollow up & Interval Hx
It does not hurt to ask a patient “how are you?”It does not hurt to ask a patient “how are you?”
intermittently. Do not advance the clock if you needintermittently. Do not advance the clock if you need
to put some other orders at the same time.to put some other orders at the same time.
Obtain interval history/follow up in patients withObtain interval history/follow up in patients with
distress. They might give you some valuabledistress. They might give you some valuable
feedback that may change your treatment strategy.feedback that may change your treatment strategy.
Once they are stabilized and comfortable , go backOnce they are stabilized and comfortable , go back
and get interval history. If they did not give you fulland get interval history. If they did not give you full
history at presentation, they will give it to you now!history at presentation, they will give it to you now!
Obtaining this full history may sometimes, help inObtaining this full history may sometimes, help in
further treatmentfurther treatment
Drug side effects – Order panels during follow upDrug side effects – Order panels during follow up
visits – liver panel, lipid panel etc to follow up yourvisits – liver panel, lipid panel etc to follow up your
drug side effects as well as the efficacy.drug side effects as well as the efficacy.
Ordering follow up tests at a later date worksOrdering follow up tests at a later date works
only on the 2 min screenonly on the 2 min screen

40. Follow up appointmentsFollow up appointments
Schedule follow up appointments for officeSchedule follow up appointments for office
visits where required and then advancevisits where required and then advance
clock to get them back in your office.clock to get them back in your office.
Take follow-up history each time you visitTake follow-up history each time you visit
an inpatient or during out-patient follow upan inpatient or during out-patient follow up

41. CounselingCounseling
Needed in all office visitsNeeded in all office visits
Usually done on 2-minute screen as you can choose multiple counselUsually done on 2-minute screen as you can choose multiple counsel
options at once here using a control button. This prevents your “real time”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 havefrom being wasted in the active case for these routine orders. If you have
other “later” orders that are relevant to “monitoring” in that case, enterother “later” orders that are relevant to “monitoring” in that case, enter
those first before entering these “routine” counseling orders so that youthose first before entering these “routine” counseling orders so that you
do not run out of your valuable time on 2 min screen .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.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.Routine counseling may not be scored at all after 2 min screens are introduced.
Counsel on appropriate issuesCounsel on appropriate issues
- Weight loss, exercise, diet, smoking & alcohol cessation- Weight loss, exercise, diet, smoking & alcohol cessation
- Driving with seatbelt- Driving with seatbelt
- Safe sexual practices- Safe sexual practices
- Asthma careAsthma care
- Avoid stat counseling unless extremely needed. Like in panic attack /Avoid stat counseling unless extremely needed. Like in panic attack /
nervous patient. Some counsel orders are importantnervous patient. Some counsel orders are important at the initial visit itselfat the initial visit itself
–– DO NOTDO NOT wait until 2 min screenwait until 2 min screen ( counsel, cancer diagnosis, home( counsel, cancer diagnosis, home
glucose monitoring, smoking cessation, sexual partner needs treatment,glucose monitoring, smoking cessation, sexual partner needs treatment,
using epipen, counseling asthma care and side-effects in childhoodusing epipen, counseling asthma care and side-effects in childhood
asthma etc in appropriate case scenarios).asthma etc in appropriate case scenarios).

42. Appropriate screening for officeAppropriate screening for office
visitsvisits
Age specific screeningAge specific screening
You will be credited for thisYou will be credited for this
If the patient came with an acute problem,If the patient came with an acute problem,
address the acute problem and diagnosticaddress the acute problem and diagnostic
work-up on the active screen. You canwork-up on the active screen. You can
always do Screening on the 2-minutealways do Screening on the 2-minute
screen by scheduling them for a “later”screen by scheduling them for a “later”
date.date.

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

44. Indications for admission in anIndications for admission in an
office visitoffice visit
LocationLocation
Look at vitals in office visit. A severe symptomatology may require statLook at vitals in office visit. A severe symptomatology may require stat
orders – cbc, chem., cardiac enz, ekg, iv access – if something unstable ororders – cbc, chem., cardiac enz, ekg, iv access – if something unstable or
serious or if indications of admission are present as per labs/ vitals orserious 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 enteringinability to take PO meds – send pt to ER and then admit. After entering
ER, address initial problem and then only transfer to floor/ICUER, address initial problem and then only transfer to floor/ICU
Indications for admission in office – pneumonia case ( CURB 65 –Indications for admission in office – pneumonia case ( CURB 65 –
CONFUSION, UREMIA, RR>30, SBP<90, AGE>65)CONFUSION, UREMIA, RR>30, SBP<90, AGE>65)
Indications for admission in office – Pyelonephritis/ PID caseIndications for admission in office – Pyelonephritis/ PID case
Obtaining consults for office visits i.e; colonoscopy( anemia, weightloss,Obtaining consults for office visits i.e; colonoscopy( anemia, weightloss,
constipation), EGD(weightloss, heartburn, anemia, Dysphagia, persistentconstipation), EGD(weightloss, heartburn, anemia, Dysphagia, persistent
vomiting, age) , bronchoscopy (lung mass), cystoscopy (hematuria) etc –vomiting, age) , bronchoscopy (lung mass), cystoscopy (hematuria) etc –
order consult as routine, see the report time of consult procedure and thenorder consult as routine, see the report time of consult procedure and then
schedule follow up visit after the consult report is obtained.schedule follow up visit after the consult report is obtained.

45. Sending Patient home from OfficeSending Patient home from Office
LocationLocation
Do not keep patient waiting in the office. AddressDo not keep patient waiting in the office. Address
their current symptoms, hit move patient button,their current symptoms, hit move patient button,
schedule a follow up visit, usually in a week (payschedule a follow up visit, usually in a week (pay
attention to result report time while schedulingattention to result report time while scheduling
follow ups)follow ups) You do not want pt to come to yourYou do not want pt to come to your
clinic for follow up even before you got the testclinic for follow up even before you got the test
result. – you can always call her back if somethingresult. – you can always call her back if something
dangerous comes out on labs even prior to thedangerous comes out on labs even prior to the
next follow up visit. – hit the move patient icon.next follow up visit. – hit the move patient icon.

46. Moving the PatientMoving the Patient
LOCATIONLOCATION
Can not use “ transfer to icu” order on theCan not use “ transfer to icu” order on the
2 min screen2 min screen
Moving the patient home while awaitingMoving the patient home while awaiting
orders on Clinic case – after addressing onlyorders on Clinic case – after addressing only
the current symptomsthe current symptoms
Schedule follow up office visitSchedule follow up office visit
Order follow up labs for pts on certainOrder follow up labs for pts on certain
drugs eg: lipid Panel, lfts etcdrugs eg: lipid Panel, lfts etc

47. 2-minute screen2-minute screen
You cant change location or obtain resultsYou cant change location or obtain results
PRIORTIZE! Prioritize! Prioritize your orders!PRIORTIZE! Prioritize! Prioritize your orders! You ONLY have 2You ONLY have 2
minutes. Important treatment and monitoring orders first and then,minutes. Important treatment and monitoring orders first and then,
specific counseling if not already done and then only, routine counselingspecific counseling if not already done and then only, routine counseling
and screening!and screening!
If you did not have time to put your essential treatment orders and theIf you did not have time to put your essential treatment orders and the
case ended , put them nowcase ended , put them now
Discontinue unnecessary orders at this time ( if unnecessaryDiscontinue unnecessary orders at this time ( if unnecessary at that pointat that point
simulated timesimulated time))
Add discharge home medications if patient simulated time and if patientAdd discharge home medications if patient simulated time and if patient
clinical situation meets discharge criteria.clinical situation meets discharge criteria.
If patient is ready to go home, switch IV meds to oralIf patient is ready to go home, switch IV meds to oral
Do counselingDo counseling
Is your patient eating?- if not already put , enter diet orders.Is your patient eating?- if not already put , enter diet orders.
Monitoring for later dateMonitoring for later date : VERY IMPORTANT ( you can do this only on: VERY IMPORTANT ( you can do this only on
2 min screen)2 min screen)  enter follow-up tests at aenter follow-up tests at a laterlater date i.e; following drugdate i.e; following drug
toxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INRtoxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INR
monitoring etc), following disease activity ( follow up TSH etc)monitoring etc), following disease activity ( follow up TSH etc)
 Enter elective screening tests for aEnter elective screening tests for a LATERLATER date in an inpatientdate in an inpatient
i.e; colonoscopy, pap smear, mammogrami.e; colonoscopy, pap smear, mammogram
Enter age appropriate and disease appropriate vaccines if not enteredEnter age appropriate and disease appropriate vaccines if not entered
beforebefore

48. Use control button – Save “Real timeUse control button – Save “Real time
Arthrocentesis ordersArthrocentesis orders
Fluid analysis ordersFluid analysis orders
Counseling orders on the 2 min screenCounseling orders on the 2 min screen
Other orders like:Other orders like:
• ““diabetic”diabetic”
• ““cardiac”cardiac”
• ““Oxy” etcOxy” etc

49. Do not waste time staring at the screenDo not waste time staring at the screen
– Save “Real” time– Save “Real” time
With new changes in Feb 2012, you only have “With new changes in Feb 2012, you only have “activeactive” REAL times of 18” REAL times of 18
minutes and 8 minutes for long and short cases respectively . You mustminutes and 8 minutes for long and short cases respectively . You must
reach diagnostic, therapeutic and “reach diagnostic, therapeutic and “immediateimmediate” monitoring goals for that” monitoring goals for that
case in this time. To reach these goals in certain cases, you will need tocase 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:advance the clock much farther in patient “simulated” time ( For example:
in DKA case, anion gap does not close for a long time). “in DKA case, anion gap does not close for a long time). “LaterLater””
monitoring goals can be achieved on 2 min screen.monitoring goals can be achieved on 2 min screen.
You must practice thoroughly.You must practice thoroughly.
You need to be very fast with navigationYou need to be very fast with navigation
Master Archer strategies and practice them several times.Master Archer strategies and practice them several times.
Have a quick plan for treating and then, monitoring. Once you have aHave a quick plan for treating and then, monitoring. Once you have a
plan ,plan , YOU MUST MOVE AHEAD WITH CLOCK NAVIGATIONYOU MUST MOVE AHEAD WITH CLOCK NAVIGATION -----start-----start
“advancing” the clock to get to your goal fast!“advancing” the clock to get to your goal fast!

50. Cases ending before timeCases ending before time
Why do many cases end quickly? – how will I know if IWhy do many cases end quickly? – how will I know if I
did well if case ended quickly ?did well if case ended quickly ?
 That is the reason why you need to check intervalThat is the reason why you need to check interval
history and vitals often.history and vitals often.
 This is the reason you need to monitor your laboratory orThis is the reason you need to monitor your laboratory or
clinical parameters (physical, vitals) pertinent to thatclinical parameters (physical, vitals) pertinent to that
casecase
 If monitoring parameters are improving and if caseIf monitoring parameters are improving and if case
ended before allotted “real” time, it means you haveended before allotted “real” time, it means you have
done very well .done very well .
 If monitoring parameters are deteriorating and if caseIf monitoring parameters are deteriorating and if case
ended before allotted “real” time, it means you haveended before allotted “real” time, it means you have
NOT done well.NOT done well.

51. ChecklistChecklist
Imaging & EKGImaging & EKG
EKG, EEG, Echo, Ultrasound, Carotid DopplerEKG, EEG, Echo, Ultrasound, Carotid Doppler
CXR, X ray Joints, acute abdominal seriesCXR, X ray Joints, acute abdominal series
CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.
Nursing ordersNursing orders
NPO, Diet, IV Fluids, Vitals, Input/output, PhysicalNPO, Diet, IV Fluids, Vitals, Input/output, Physical
therapytherapy
Tubes- NG, FoleyTubes- NG, Foley
Pulse oximetry & Oxygen, cardiac monitorPulse oximetry & Oxygen, cardiac monitor
Medication ordersMedication orders
CounselingCounseling
Weight loss, exercise, diet, smoking & alcoholWeight loss, exercise, diet, smoking & alcohol
cessation.cessation.

52. ChecklistChecklist
Labs:Labs:
CBC, CMP, Urine routine, TSH, Lipid Profile,CBC, CMP, Urine routine, TSH, Lipid Profile,
Cardiac enzymes, ABG, Glucometer check,Cardiac enzymes, ABG, Glucometer check,
Drug levels, Toxicology screen-Urine andDrug levels, Toxicology screen-Urine and
serum, ANA, ESR.serum, ANA, ESR.
– Bleeding & pre-op pts– Type Blood and crossBleeding & pre-op pts– Type Blood and cross
match, PT/INR, PTT.match, PT/INR, PTT.
– Infections – cultures of Blood, Urine, Sputum orInfections – cultures of Blood, Urine, Sputum or
CSF, as appropriate.CSF, as appropriate.
– Acute abdomen – order amylase, lipase, b HCG &Acute abdomen – order amylase, lipase, b HCG &
acute abdominal X ray series.acute abdominal X ray series.

53. Our Social NetworksOur Social Networks
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54. DyspepsiaDyspepsia
- If warning signs or age > 50,- If warning signs or age > 50,
please do EGDplease do EGD
-If doing EGD, add biopsy, gastricIf doing EGD, add biopsy, gastric
mucosa – H.pylori stain.mucosa – H.pylori stain.

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

56. Acute MIAcute MI
EKG will decide further MxEKG will decide further Mx
EKG will take 15 minsEKG will take 15 mins
Thrombolytics vs. cardiac CathThrombolytics vs. cardiac Cath
What if similar to dissection? Think of yourWhat if similar to dissection? Think of your
“Triad”“Triad”
Pericarditis – the EKG differences. LookPericarditis – the EKG differences. Look
“reciprocal depressions” are not seen in“reciprocal depressions” are not seen in
pericarditispericarditis

57. StrokeStroke
TIA – Thrombotic vs.EmbolicTIA – Thrombotic vs.Embolic
CT headCT head with outwith out contrastcontrast
ASA vs. AggrenoxASA vs. Aggrenox
EKG, 2D Echo to r/o cardiac originEKG, 2D Echo to r/o cardiac origin
Carotid doppler to r/o carotid stenosisCarotid doppler to r/o carotid stenosis
If carotid stenosis and meets criteria ?If carotid stenosis and meets criteria ?  CEACEA

58. ShockShock

59. Respiratory FailureRespiratory Failure

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

61. HUSHUS
 Diarrhea preceding PresentationDiarrhea preceding Presentation
R/o other causes of microangiopathic hemolysisR/o other causes of microangiopathic hemolysis
Demonstrate schistocytes on peripheral smearDemonstrate schistocytes on peripheral smear
Supportive theray as initial choiceSupportive theray as initial choice
Monitor CBC and BMPMonitor CBC and BMP
If Clinical picture worsens, get plasmapheresisIf Clinical picture worsens, get plasmapheresis
If BMP worsens, get HDIf BMP worsens, get HD

62. Delirium in ElderlyDelirium in Elderly
Sun downingSun downing
DementiaDementia
Sepsis : UTI, Pneumonia andSepsis : UTI, Pneumonia and
C.difficleC.difficle

63. Secondary HypertensionSecondary Hypertension
HyperaldosteronismHyperaldosteronism
Hypokalemia with leg crampsHypokalemia with leg cramps
Get hormonal tests ( PAC/ PRA) prior to CT imagingGet hormonal tests ( PAC/ PRA) prior to CT imaging
Spironolactone as medical therapySpironolactone as medical therapy
CT may show adrenal adenomaCT may show adrenal adenoma
Call surgical consultCall surgical consult
If accepted, order adrenalectomyIf accepted, order adrenalectomy

64. Our Social NetworksOur Social Networks
Join several thousands of Archer Review fans onJoin several thousands of Archer Review fans on
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Follow us on twitter for updatesFollow us on twitter for updates
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• Connect with us on LinkedIN atConnect with us on LinkedIN at
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 Access our Sample Free Questions for USMLEAccess our Sample Free Questions for USMLE
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