Pulmonary Embolism Management Flowchart

Suspect PE in any question stem with sudden onset Short of Breath with / without pleuritic chest pain - especially with clear breath sounds and a clear X-ray.

If the patient is unstable - first thing to do is a shot of Heparin, if not, the first investigation done for PE is the Ventilation Perfusion Scan. The following Diagram should clearly explain the investigation flow logic :

CCS Mnemonic: Pancreatitis Case

Management Options in the Treatment for Pancreatitis (Especially Useful for CCS cases)


"PANCREAS"

P - Pain Control
A - Aspiration by Naso-Gastric Tube
N - NPO
C - Calcium for Hypocalcemia
R - Replenish Fluids
E - Enteric Feeds or TPN depending on the case
A - Antibiotics (Imipenem)
S - Surgery in case of Abscess or Pseudocyst development

And of course, For any acute Abdominal Emergency - remember the 4 "N"s to be done at first :

Nil By Mouth (NPO)
Naso-Gastric Tube
Needle Infusion of IV Fluids
Narcotics for the pain (Meperidine preferred)

CCS MNEMONIC : Basic Orders on patient admission

Don't forget these basic orders if you admit a patient on a CCS case. For that matter, first of all, do not forget to have the patient sent to the inpatient floor after you are done stabilizing the patient who showed up with an emergency and needs continuing observation or Intravenous fluids / Drugs. This is important - you will tend to forget and is a common error.



"ADMIT"

A - Activity (Bed rest ? , restricted movements ?, etc)
D - Diet (NPO, Diabetic Diet ? , etc)
M - Medications (Switch to oral if possible)
I - Investigations (Labs) + Input/Output Monitoring + IV Fluids (with frequency)
T - TPR (Temp. Pulse.pressure.Resp.) i.e. Vitals ...with frequency

:-)

MUSA'S Golden CCS Rules for Step 3 CCS

This is to the point and great !

"1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
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31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin"

CCS Mnemonic: Orders for a Case of Trauma

A Case of Trauma can often be a TRAUMATIC EXPerience - not only to the patient but also to the doc since so many different orders need to be taken care in pretty less time.

Lets use the phrase "TRAUMATIC EXPerience" to help us remember the orders to keep in mind on the USMLE Step 3 CCS , once you have done the basic Stabilization (ABC):

Note:
1. These orders are not necessarily in the right order, you can change the sequence on the CCS screen after you type them out...
2. Not all orders will be applicable to some cases - this mnemonic is to be used as a guideline

"TRAUMATIC EXP"

T - Typing + Cross Matching of Blood
R - Routine Labs [CBC, BMP, LFTs]
A - Alcohol levels, blood + ABG (trauma can result in lactic acidosis)
U - Urine Analysis + Urine Drug Screen if Pt. known drug abuser
M - Morphine for pain (Meperidine if biliary / pancreatic system injury suspected)
A - Amylase for Abdominal Injuries
T - Transfer to ICU / Ward
I - IV Fluids
C - Consult Surgery, Orthopedics, etc ; CT-scans if Pt. Stable OR bedside USG if not

E - EKG 12 Lead
X - Xray Relevant
P - PT / PTT



Again, these orders are AFTER the basic first orders like Oxygen, Endotracheal tube if needed, Continuous BP Monitoring, Pulse Oxy, IV access + Cervical Spine Immobilization + Physical Examination.

Additions, Suggestions and Modifications are welcome - leave us a comment !