Diagnosis therapy - monitoring timing location sequencing

All cases:
Age
Sex
Allergy
Social habits: smoking/drinking/exercise

*Always CCC: Comfort, Consult & Council

ER protocol orders: POLICE-S

Pulse Oximetery
Oxygen
Line access
IV fluids- NSS
Cardiac & BP Monitor, CXR
ECG/Elevate bed
Sugar-Finger stick glucose
* Bowel rest: NPO & NG tube
*P/E: general + appropriate systems only (1-2) >> complete PE after
stabilization >> Admit

Mediations:
Fever- Acetaminophen
Vomiting- IV Phenergan
Constipation- docusate
Diarrhea-Loperamide
Severe somatic pain- Morphine, except CBD stone -Mepiridine
Severe body pain- naproxen
Chest pain- ASA + sublingual NG
Agitation- Lorazepam
Abdominal cramps- Hyoscine
Abx:
Pre-op > cefazolin
Bacteria rhino sinusitis > Augmentin or levofloxacin
Cholecystitis > pipercillin-tazobactam or Vancomycin

Orders:
Blood- CBC, BMP, PT/PTT/INR, Lipid Profile, TSH, B. culture
Other- ECG, PEFR, ABGs, Stool for ova/WBCs/bacterial culture/C. difficile
Urine- UA, U. culture, U. toxicology
Pregnancy- B-hCG
Imaging- acute abdomen x-ray series, USG, CT, MR

Admission orders: PANIC-R

PPI
Activity- bed rest
NPO
In/output & IV fluids
Compression- pneumatic stocking / LMWH SQ
Repeat v/s & labs as needed

Pre-op orders:
PT/PTT/INR/Blood group & cross match
Abx-IV Cefazolin once, metronidazole & ciprofloxacin if GI
NPO/NG tube
Consent/Consultation
IV access and IV NSS
Pneumatic compression stocking/ LMWH SQ

Counseling:
Smoking
Alcohol
Diet
Exercise
Self breast exam
Seat belt
Medication compliance/adherence
Cancer diagnosis/HIV support group
Suicide contract
*Council parent/educate parents in pediatric cases
Social worker/child protection service
*Screening, check age and gender
notify public health department if HIV/TB
 Cases notes:
HTN- life style modifications for 6 months
Cancer- counseling cancer diagnosis
Polymyalgia rheumatica- steroids
Prednisone- add PPI & Ca & Vit. D3 & DEXA scan
Suspected HIV infection- do serum ELISA, if + western plot/CD4/Viral load
Lithium therapy- Do TSH/ CBC/ B-hCG / Creatinine
Before colonoscopy- give polyethylene glycol preparation
Hyperkalemia- ECG > Insulin & Glucose > Ca++ gluconate
Dysfunctional UB- Hemoglobin: NL > Iron supplement, 10-12 > bleeding?
Progestin only OCP, if not combined OCP, <10 > hospitalize and give estrogen IV
Bed ridden- DVT prophylaxis
Bowel- PPI & NGT
Vaccinations-
AAA- ICU admission
Menopause- Vit D, Ca, HRT
Suicide contract
Trauma- C-spine immobilization
Cystitis- always order B-hCG if female in reproductive age & order U. culture in
2 weeks to confirm eradication
Abx: TMP/SMX, If allergic > Ciprofloxacin
If pregnant > Nitrofurantoin, if allergic > Augmentin
Pregnancy- B-hCG & TV-ultrasound to confirm pregnancy
Once confirmed order:
Atypical AB titer,
Blood group & Rh
CBC, BMP
UA & U. culture
HIV ELISA, syphilis RPR, Chlamydia, Rubella Abs, HBs Ag
Multi-vitamins &Iron sulphate & folic acid
OGTT 24-28 weeks
IBD- flexible sigmoidoscopy/colonoscopy & biopsy to confirm as well as
A. W/u: Stool for ova/WBC/bacterial cultures to r/o other causes
B. Tx: topical meselamine, oral meselamine/sulfasalazine, symptomatic Tx for
diarrhea and abdominal cramps

IBS-
A. Workup: CBC, BMP, TSH, FOBT, triple Stool test, 72hr stool fat
B. Tx: symptomatic treatment for abdominal cramps and diarrhea, high fiber
lactose free diet, reassurance & relaxation exercise, behavioral biofeedback
therapy

Depression
A. Workup: TSH/ B12 plus CBC/BMP
B. Tx: Fluoxetine lorazepam if anxiety/insomnia and follow up weekly for 6-8
weeks
C. If suicidal ideation: admission, psychiatric consultation & ECT
 Vaginal discharge-
A. Workup: vaginal PH/wet mount/G stain/GC & Chlamydia culture, UA, Pap-
smear
B. Tx:
Candida- oral fluconazole & local miconazole
Bacterial vaginosis- oral or topical metronidazole
Trichomonas- oral metronidazole & partner & avoid alcohol
Alzheimer Disease- labs>Dx>Tx>f/u in 6wks
A. Dementia work up: TSH & B12 & brain CT/MR
B. Tx: Donepezil + memantine + Vit. E
C. Address co-existing psychosis> olanzapine, anxiety>buspirone,
depression>fluoxetine
D. Counseling: cognitive rehabilitation, support groups, no driving
COPD exacerbation:
A. Work up: Pulse Oximetery/ABGs (PaO2), CXR, PEFR,
B. Tx:
Acute: O2 + Albuterol/Ipratropium + Prednisone + Abx (TMP-SMX OP)/
(Ceftriaxone IP)
*NIPPV if Pao2 < 45 or PH 7.3
*ICU if severe respiratory distress/acidosis and hypoxemia despite O2
*On Admission: change Neb to MDI &IV steroid to PO
C. Influenza & Pneumovax vaccines
Breast mass evaluation:
A. Age 30 US FNA
B. Age 30 Mammography US FNA
C. Cyst > no further management unless symptomatic> aspirate
D. Complex cyst > FNA, if bloody, cytology, if + excise, if f/u in 4 weeks
E. Solid suspicious > excise

HTN urgency/emergency-
A. w/u: CT head 1st always r/o stroke before starting BP treatment
B. Tx: IV nitroprusside (labetalol, nicardipine) & ICU & arterial line for BP
monitoring over 2-6 hours target (DBP =100 or decrease 25%) then transfer to
floor/DC arterial line/PO medications then home

Suspected FB aspiration-
A. w/u: neck & chest -x-ray
B. Tx: O2 & rigid bronchoscopy
Panic attack-
A. w/u: TSH, Urine toxicology, CXR to rule out DD
B. Tx: Alprazolam & reassurance & council no caffeine/nicotine/alcohol

TIA- order CT head with ER orders to r/o he, if give aspirin

*Admit if 1st time TIA, symptoms > 1hr, A.fib/hypercoagulable, stenosis>50%
A. w/u: CT head & carotid Doppler & echo & lipid profile
B. Tx: Aspirin clopidogril
C. CEA if > 70-99% stenosis & consult vascular surgery & cefazolin before
surgery

Bleeding workup- PT/PTT, INR, BT, CBC, LFT

*Isolated prolonged PTT, suspect intrinsic pathway > order factor VII, IX, XI
*Tx: confirm factor deficiency then treat, Hemophilia A-8, Hemophilia B-9
*Monitor with PTT/factor level
*Counseling: genetic consult, No aspirin, No contact sports
Giant cell arteritis-
W/up: basic labs & ESR/CRP & CXR (Aortic vasculitis), Biopsy.
Tx: start prednisone & Aspirin before biopsy result
F/U: CBC/ESR/CRP
HSV encephalitis-
W/up: basic labs & LP & basic CSF analysis & CSF HSV by PCR & CT head
Tx: start Acyclovir before PCR result

Cryptococcal meningitis-
W/up: serum cryptococcal antigen & head CT then basic CSF analysis & CSF
cryptococcal antigen/India ink
Tx: IV amphotericin & flucytosine >> PO fluconazole

Bacterial meningitis- if unstable, do blood Cx and start empirical Abx

Ceftriaxone & Vancomycin then do CT head & LP, otherwise do LP 1st
W/up: basic CSF analysis
Tx: add steroids (D/C if pneumococcal meningitis excluded).
Cocci G+ Ceftriaxone & Vancomycin
Cocci G- Ceftriaxone
Bacilli G+ Ampicillin & Gentamycin
Bacilli G- Ceftriaxone & Gentamycin

Acute manic episode Tx -

1. Diazepam/olanzapine for agitation & suicide contract
2. Lithium as mood stabilizer
3. Psychotherapy

RA- NSAIDs/Prednisone + Methotrexate

Aortic dissection- Labetalol nitroprusside & morphine then surgery
Asthma- albuterol inh. & Oral prednisone
DKA- ICU IV NSS & regular insulin Abx
Finger stick & ABGs hourly, serum osmolality & ketone bodies

Pre-eclampsia/ Eclampsia Fetal monitor, Rule out HELLP, CBC/LFT/PT/PTT

Hydralazine & MgSo4 then C-section/Gyn
 Pneumonia- Do CXR AP & Lateral
Azithromycin OP healthy, Ciprofloxacin OP co-morbid, IV levofloxacin IP
(unstable vitals, require O2/low O2 sat)

Acute pancreatitis- Do TG & Abd CT ERCP/surgery if gallstone pancreatitis

ICU symptomatic Tx Abx if necrotizing (imipenem)

SCD vaso-occlusive crisis Do CXR (r/o acute chest syn.) & reticulocyte count
Tx: NSS & Morphine & NASIDs
Abx if acute chest syndrome- azithromycin
Blood transfusion if severe anemia
+ Hydroxyurea to prevent relapse

Ectopic pregnancy- urine B-hCG & Transvaginal US

*MTX if stable & B-hCG< 5000 & adnexal mass< 3.5 cm, no renal/liver failure
>> Follow up with B-hCG serum quantitative
*Surgery if unstable &B-hCG 5000 &adnexal mass> 3.5 cm, + fetal activity
*If Rh- prescribe RH immunoglobulin after treatment

GERD- endoscopy & esophageal Bx

PPI & life style modification (smoking/ alcohol/ sit after meals)

Intussusception- AXR & abdomen US

Hydration & Morphine & barium enema
*Admit for 24 hours observation

Sigmoid volvulus- abdomen acute series

Flexible sigmoidoscopy or rectal tube & surgical consult

SBO- abdomen acute series & CT

Bowel rest NG tube/NPO & Surgical consult & repair

APCKD- abdomen US/CT, UA, consult nephrology/surgery

*ACEI & low Na diet for HTN
*MRA brain if FH of stroke

Ovarian CA- US & CA-125/FP/serum B-hCG & paracentesis/ fluid cytology

Surgical consult/laparoscopy & oncology consult

PID- B-hCG & vaginal PH, wet mount, KOH & UA/Cx & Cervical G-stain/GC/C
culture & RPR & HIV ELISA & HBsAg check cervical culture then treat
*(IN)- IV clindamycin & gentamycin + oral Metronidazole if TOA
*(OP)- Ceftriaxone inj. + doxycycline + Metronidazole
*Admit if severe abd. Pain, high fever, inability to take PO, pregnancy, TOA
*Symptomatic treatment for fever, N/V and abdominal pain
Perforated PUD- abdomen acute series & CT & DD: lipase, troponin-I
Bowel rest & Morphine & surgical consult
*Pre-op PPI & Abx metronidazole/ciprofloxacin

Mesenteric ischemia- abdomen acute series & CT

Bowel rest & Morphine & surgical consult
*Pre-op Abx metronidazole/ciprofloxacin

Splenic trauma- FAST then CT abdomen

Admit, ICU if > 3 cm or > 50% hematoma

Diverticulitis- abdomen CT
*Uncomplicated- Abx metronidazole + ciprofloxacin
*Complicated- (peritonitis, severe pain, o-morbid) Admit & consult surgery
IV metronidazole + cefotaxime

Fatigue DD: cancer, chronic disease TSH/T4, LFT, Iron studies, depression
index, glucose fasting, UA

Colon CA- colonoscopy & Iron study & CEA

Colectomy & consultation
F/up with CBC and CEA in one month

DM- HbA1c, urine micro albumin, KFT, lipid profile

Tx & vaccinations
F/up with HbA1c after 3 months

Lead poisoning- venous lead level & iron studies

Inform lead agency & iron-enriched formula
45-69 >> succimer
70 >> admit & EDTA

Anorexia nervosa- ECG & BMP/Mg/PO4

If amenorrhea, B-hCG & prolactin & FSH
Admit if electrolyte disturbance

Gastritis/ peptic ulcer disease- endoscopy & H pylori testing

PPI clarithromycin & Amoxicillin
*H. Pylori stool antigen in 4 weeks

Childhood leukemia- BM Bx & BM aspiration, uric acid, LDH, cultures, LP & CSF
cytology
Chemotherapy transfusions
Chest pain- ECG, CXR, Echo, Troponin-I, D-dimer, CBC/BMP/UA

Acute pericarditis- check ECG & do Echo

Naproxen & rest

Acute panic attack- rule out MI/PE. Order ECG & Troponin-I/D-dimer
Alprazolam & reassure & consult psychiatry

SLE- ANA, Anti-ds DNA, Anti-smith

NSAIDS, sun screen & avoid sun, Hydroxychlorquine steroids if low platelets

Altered mental status- ABGs, ECG, finger-stick glucose, Head CT, UA &
culture & toxicology screen
Mx: NG tube, ET-tube/Ventilator, Foleys catheter/urine output
*Activated charcoal/gastric lavage

Turner syndrome- FSH/LH, TSH, Bone Age, Karyotyping, echo, abdomen US

Tx- GH if BA<14 & Estrogen conjugated & Vit D/Ca

Hemolytic anemia- CBC, bilirubin, reticulocyte count, LDH,

 Pay close attention to the setting (location) of the patient encounter. The setting
helps you decide on the aggressiveness of your treatment orders and whether to send
the patient home. It also gives a clue to the medical diagnosis.

If the setting is ER and you are not sure of the medical diagnosis, admit the patient
and work him up. You can always discharge him from the hospital, the next day. USMLE
Step 3 CCS is testing you to see if you practice safe medicine. One year of medical
residency should help you in your decision-making.

Write down the age, sex, chief complaint, and allergies of the patient on the writing
sheet provided at the exam. This will help you save time when considering medical
differential diagnosis.

Counseling is a major part of outpatient office visits. Pay particular attention to

counseling in normal/ routine patient visits. This is similar to real counseling provided
by you in your medical residency.

Important counseling topics include smoking, alcohol, drugs, safe sex practices,
exercise, weight reduction, diet, and self-breast exam. You can score points for these
orders in the USMLE Step 3 CCS test.

If the patient presents with breathing difficulty, remember to order Oxygen,

albuterol PRN and hook him up with a pulse oximetry.

Patients presenting to the ER in an unresponsive state should have a finger stick

glucose done with a glucometer stat, Naloxone given if opiates are suspected (Pupils),
and thiamine added to IV fluids if alcoholic.
 Patients with Hypertension and diabetes should have appropriate diets ordered (2
gm. salt restricted or 1800 ADA diet)

For abnormal LFTs order hepatitis profile/panel if appropriate. USMLE CCS exam
assesses the appropriateness of medical orders.

Order tests to diagnose H. pylori if patient has GERD. The H. pylori antibody should
be ordered if the patient has never been diagnosed before and the Urease breathe test if
checking for elimination/ recurrence.

Overdose/poisoning patients should be admitted to the ICU for closer monitoring

and suicide precautions. Dont forget to get a Psychiatry consult.

Inpatient hospital admissions need a physical exam everyday and appropriate lab
and medical orders. Remember what you do daily in your residency, and you will be fine.

When writing orders, you can save time by holding down control and selecting
multiple orders with your mouse.

Acute abdomen and most surgical emergencies need frequent and multiple interval
H&P.

Dont forget to advance the clock during the USMLE Step 3 CCS exam. Remember, you
will not get results and nothing will happen until you advance the clock.

Get appropriate consults. You will get credit for this. However, once you ask for a
consult, the computer may ask you to manage it yourself temporarily, as the consultant
is busy. Dont worry. Do the routine pre-op stuff and stabilize the patient.

Use keywords to get order lists- Stop, Avoid, Diet, Vaccine, Advice etc.

Have a routine scheme / checklist to follow for USMLE CCS exam. This avoids
overlooking common orders. You can even write down this checklist on the writing
sheet provided at the USMLE testing center. You can then rapidly refer to the checklist
(see below) and make sure that you have not forgotten anything.

In the ER setting, first do a brief physical exam (2 min). Then write orders and labs.
Once the patient is stabilized and lab results reviewed, do a full physical exam. Then
shift the patient to the ICU or ward.

Remember First stabilize, then full physical, and then admit. This is also what you
would do, in your residency training and real life.

When ordering labs in the ER, avoid asking for panels (e.g. CMP or BMP), the results
will be delayed. Instead order the individual components of the panel. You can order
panels in other settings.