CCS - episode 1
TheOne - 04-05-07 19:52

This series is to help you understand the steps of management required by you to pass the CCS part of Step 3, Give us your feed back to help you ace the test...

Use The following as template to work with cases:
History of present illness:
Note the vital signs: BP, Pluse, Resp.Rate, Temp.
Check vitals to make sure the patient is hemodynamically stable.
Pay attention to quality of pain,dull, sharp, pleuritic, constant, etc. this can give you clues to the possible cause. For example pleuritic pain make you think of pericarditis, pulmonary embolism, pneumothorax, pneumonia, and infectious pleuritis.

You should formulate a differential diagnosis after you have read presentation and vital signs. Determine if the patient needs immediate care, if so do step I.

Step I: Emergent management:
A, B, C, D

Step II: Physical Examination:
Complete vs focus depending on situation. If someone is in your office for annual check or routine visit you should do a complete exam.

Step III: Diagnostic Investigations & Treatment:
Think which one of the labs or imaging you need to do to give you more clues to make your diagnosis.

Imagining:
1- CXR
2- EKG
3- Echocardiogram
4- CT
5- USG
6- Colonoscopy-sigmoidoscopy
7- Barium enema or swallow
8- Bronchoscopy - rigid or flexible
9- VQ scan - Venogram
10- Doppler U/S
11- ERCP

Labs:
1- CBC
2- Chem 8/12
3- Lipid profile
4- LFT
5- Urinalysis
6- Cardiac Enzymes
7- C&S
8- CPK
9- TSH, free T4
10- Drug levels
11- Coagulation profile
12- D-dimer
13- Stool guiac
14- Folate, B12, peripheral smear, iron, ferritin
15- Lipase & Amylase

Treatment:
Treat if need to - if a patient has pain, give pain killer, if you suspect Pulmonary Embolisim start heparin.
Patients who needs consultaition for surgery etc. then get the consultation. If a patient needs surgery, start pre-surgical orders (CBC, BMP, PT/PTT, Blood type & cross-match, NPO at least 6h prior to the operation, EKG, CXR), you may also start Antibiotics especially for GI surgeries.

Step IV: Decision about the "Location":
After you stabilize the patient, you need to move him to the appropriate location:
- If a patient is stable and doesn't require further workup or you can manage the patient on the outpatient then discharge the patient to home.
- If the patient is found to have a cardiac problem / chest pain for example, then transfer to the CCU.
- If the patient is stable but needs further evaluation then move to ward.
When the patient is stablized, discharge home with office follow up.

Step V: Educate the patient / family:
counsel the patient on exercise, smoking, drug use, safe sex techniques, etc.

Step VI: Give the Final Diagnosis.