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CCS Workshop A component of  Archer Online USMLE Reviews WWW.CCSWORKSHOP.COM USMLE Galaxy, LLC All Rights reserved. “ Dr.Red CCS Workshop” and “Archer CCS Workshop” are the trademarks owned by USMLE Galaxy, LLC
Webinar – Muting/ Unmuting ,[object Object],[object Object],[object Object]
CCS Tips ,[object Object],[object Object],[object Object],[object Object]
CCS Tips ,[object Object],[object Object],[object Object]
“ Real” Time ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
“ Simulated” Time ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ER Setting ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Initial Step in Shock If chest clear    IV Fluids. If rales    hold IV fluids, GET EKG, then IABC and cardiac cath. Order other MI management 2 minute physical – make sure chest is clear. If rales    Left ventricular MI. Then get EKG Chestpain, sob Cardiogenic shock After 2 minute  Physical, order life saving step Pneumo – chest tube Tamponade pericardiocentesis & then window PE – Spiral ct and then tpa, hold heparin Air – trendelenberg position ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],- Chest pain/ sob – can indicate tension pneumothorax, cardiac tamponade or PE – history clues are not very suggestive    proceed to 2 minute physical Obstructive  Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Distributive  shock IV Fluid – NS boluses If suspecting hemorrhagic shock – order Type and cross match and blood transfusion right away ( Don’t wait for CBC) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hypovolemia Initial therapy Physical clues History clues Suspected cause of Shock
Respiratory Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sepsis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sepsis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Septic Shock ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case Metronidazole p.o. If resistant, use vanco p.o ( do not use I.V vanco – not effective) c.difficle Pseudomembranous colitis/ C.Difficle Diarrhea Vanco+Ceftriaxone. If listeria suspected, add Ampicillin. Give Dexametasone prior to antibiotics S.pneumonia, H.influenzae, N.meningitidis, E.coli. In ages < 1month or > 50 years -Listeria Meningitis Quinolone, ceftriaxone, extended spectrum beta lactums,   if enterococci is present    use ampicillin or vancomycin E.coli, proteus Enterococci Urinary tract infections Use good anerobic coverage : Cipro+flagyl, Pip/tazo, Ertapenem, Imipenem. Do not use cephalosporin alone ( add metronidazole if using it) Enteric gram –ve rods ( E.coli), Anerobes (B.fragilis) Intra abdominal infections ( diverticulitis) Use anti-pseudomonal drugs – PIP/TAZO + quinolone, Cefepime, Imipenem, Vancomycin (if MRSA suspected) Resistant gram –ves (ESBL), Pseudomonas, MRSA Late Hospital Acquired Pneumonia ( > 5days) PIP/TAZO, Unasyn,  Cefepime  or newer quinolone  Gram negative rods – non resistant ( e.coli, proteus, klebsiella), S.pneumonia, H.influenzae, legionella  Early Hospital Acquired Pneumonia ( < 5 days) Third generation cephalosporin + macrolide or Newer Quinolone S.pneumoniae, Legionella, mycoplasma, H.influenzae Community acquired pneumonia Emperical therapy Possible “Bugs” “ Presumed” or “Known” site of infection
ER Setting – A simple approach Address pain first and then come back to physical screen ( except in abdominal pain – do abdomen exam first and then address pain) “ “ Vitals” stable but History reveals severe “pain”  Full physical and then go to “order” sheet “ Vitals” are “Stable”  no “ Pain” Proceed to “Order sheet”  and try to stabilize. Write  “Stabilizing” orders, “Basic” orders, “Symptom” relieving orders. Write “Specific” diagnostic tests and “Specific” treatment since you already have a clue about the diagnosis from the history ( Some examples: Anaphylactic shock, Hypovolemic shock from MVA , strong clues of “PE” in the history ) “ Vitals” are “UNSTABLE” ( Shock or respiratory failure) + you have a clue about the diagnosis from the history Go to “physical screen “ – do a very focused physical ( 2 minutes – Chest and Cardiovascular. Consider “abdomen” only if history revealed abdominal pain or trauma)    Proceed to order sheet (Remember that when you have no clue from the history, a  “Life” saving step for a  severely unstable vital may not be identified until you do the “2-Minute” ( Chest, Cardiovascular) physical). Remember that if this step is done early ( less “Simulated” time),  you will get maximum score  Vitals” are very unstable + you, absolutely, have no clue about the diagnosis from the history Next Step on CCS Presenting Issue
ER setting ,[object Object]
Pain ,[object Object],[object Object],[object Object],[object Object]
ER Setting ,[object Object],[object Object]
General Approach ,[object Object],[object Object],[object Object],[object Object],[object Object]
Basic set of ER orders ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Indications for ICU admission ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
General ICU Orders ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Time required and Invasiveness – tests in ER ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Unresponsiveness in ER ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Obtaining Consults ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Using keywords ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Advancing clock ,[object Object],[object Object],[object Object],[object Object]
Before advancing clock! ,[object Object],[object Object],[object Object]
Using control button ,[object Object]
Diet orders ,[object Object],[object Object]
Follow up & Interval Hx ,[object Object],[object Object],[object Object],[object Object]
Follow up appointments ,[object Object],[object Object]
Counseling ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Appropriate screening for office visits ,[object Object],[object Object],[object Object]
Invasiveness of investigations ,[object Object],[object Object],[object Object]
Indications for admission in an office visit ,[object Object],[object Object],[object Object],[object Object]
Sending Patient home from Office ,[object Object]
Moving the Patient ,[object Object],[object Object],[object Object],[object Object]
5-minute screen ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Use control button – save time ,[object Object],[object Object],[object Object]
Cases ending before time ,[object Object],[object Object]
Checklist ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Checklist ,[object Object],[object Object],[object Object],[object Object],[object Object]
Dyspepsia ,[object Object],[object Object]
Diarrhea ,[object Object],[object Object],[object Object],[object Object]
Acute MI ,[object Object],[object Object],[object Object],[object Object],[object Object]
Stroke ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Shock
Respiratory Failure
Polymyalgia Rheumatica ,[object Object],[object Object],[object Object],[object Object],[object Object]
HUS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Delirium in Elderly ,[object Object],[object Object],[object Object]
Secondary Hypertension Hyperaldosteronism  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Step3 CCS Online Workshop Archer Review/ Dr.Red CCS workshop

  • 1. CCS Workshop A component of Archer Online USMLE Reviews WWW.CCSWORKSHOP.COM USMLE Galaxy, LLC All Rights reserved. “ Dr.Red CCS Workshop” and “Archer CCS Workshop” are the trademarks owned by USMLE Galaxy, LLC
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  • 14. Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case Metronidazole p.o. If resistant, use vanco p.o ( do not use I.V vanco – not effective) c.difficle Pseudomembranous colitis/ C.Difficle Diarrhea Vanco+Ceftriaxone. If listeria suspected, add Ampicillin. Give Dexametasone prior to antibiotics S.pneumonia, H.influenzae, N.meningitidis, E.coli. In ages < 1month or > 50 years -Listeria Meningitis Quinolone, ceftriaxone, extended spectrum beta lactums, if enterococci is present  use ampicillin or vancomycin E.coli, proteus Enterococci Urinary tract infections Use good anerobic coverage : Cipro+flagyl, Pip/tazo, Ertapenem, Imipenem. Do not use cephalosporin alone ( add metronidazole if using it) Enteric gram –ve rods ( E.coli), Anerobes (B.fragilis) Intra abdominal infections ( diverticulitis) Use anti-pseudomonal drugs – PIP/TAZO + quinolone, Cefepime, Imipenem, Vancomycin (if MRSA suspected) Resistant gram –ves (ESBL), Pseudomonas, MRSA Late Hospital Acquired Pneumonia ( > 5days) PIP/TAZO, Unasyn, Cefepime or newer quinolone Gram negative rods – non resistant ( e.coli, proteus, klebsiella), S.pneumonia, H.influenzae, legionella Early Hospital Acquired Pneumonia ( < 5 days) Third generation cephalosporin + macrolide or Newer Quinolone S.pneumoniae, Legionella, mycoplasma, H.influenzae Community acquired pneumonia Emperical therapy Possible “Bugs” “ Presumed” or “Known” site of infection
  • 15. ER Setting – A simple approach Address pain first and then come back to physical screen ( except in abdominal pain – do abdomen exam first and then address pain) “ “ Vitals” stable but History reveals severe “pain” Full physical and then go to “order” sheet “ Vitals” are “Stable” no “ Pain” Proceed to “Order sheet” and try to stabilize. Write “Stabilizing” orders, “Basic” orders, “Symptom” relieving orders. Write “Specific” diagnostic tests and “Specific” treatment since you already have a clue about the diagnosis from the history ( Some examples: Anaphylactic shock, Hypovolemic shock from MVA , strong clues of “PE” in the history ) “ Vitals” are “UNSTABLE” ( Shock or respiratory failure) + you have a clue about the diagnosis from the history Go to “physical screen “ – do a very focused physical ( 2 minutes – Chest and Cardiovascular. Consider “abdomen” only if history revealed abdominal pain or trauma)  Proceed to order sheet (Remember that when you have no clue from the history, a “Life” saving step for a severely unstable vital may not be identified until you do the “2-Minute” ( Chest, Cardiovascular) physical). Remember that if this step is done early ( less “Simulated” time), you will get maximum score Vitals” are very unstable + you, absolutely, have no clue about the diagnosis from the history Next Step on CCS Presenting Issue
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