Re: CCS Golden Rules
InSitu - 04-25-09 09:37

thanks medup

Re: CCS Golden Rules
meduploader - 04-25-09 11:35

21.altered mental status is a general case where you have to look for vital sign/if blood pressure is low and tachycardia or fever o2 saturation low towards 90 - you have to differentiate it from shock- which may be cardiogenic shock hypovolumic shock and septic shock- since it is a general case you have to do all investigation to embrace almost all the system of the body/ also, since this is an emergency case you have to start with ABCD RULE AIRWAY BREATHING CIRCULATION

22, A emergency case should have three order to be placed - one stat order / then work up order then treatment order then transfer to ICU or floor then ICU or floor order then work up then treatment and discharge with a follow up plan and counseling -- as you know which include RATED SEX

23. So, in case of shock do not forget to give oxygen - do not forget to give fluid - if septic shock do not forget to give antibiotic -

24 in case of septic shock - culture before antibiotic

25 In case of lumbar puncture do ct before LP

26. In case of temporal arteritis, start steroid before biopsy- because delay can cause blindness

27. In case of suspected bacterial meningitis, give antibiotic before lumbar puncture because delay can kill

28. In case of pnemonia as soon as you get the xray you must give antibiotic as soon as possible

29.In case of nonaccidental trauma or child abuse you have to differenciate from accidental trauma and diseases like ostteogenenetic imperfecta social culture and bruises you have to differentiate from congenital or acquired bleeding disorder by ptt ptt bleeding time -- you have to all general lab and do skeletal survey cxr ct

30 in suspected child abuse case do ophthalmology exam and consult do see retinal hemorrhage /do surgery consult if surgical intervention necessary / do child protection service evaluation . do social service consult/neurosurgical consult if neurological deficit or ct shows hemorrhage

31 suspected child abuse case must be admitted to hospital

32. of course you have to symptomatic treatment and life saving treatment as well. Patient may need to be ventilated /fluid resucicitation may be necessaray

Re: CCS Golden Rules
bobby - 04-25-09 12:41

Thats really good list of Rules.meduploader,hope you are going to post more on the "CCS Golden Rules".Thanks.

Re: CCS Golden Rules
meduploader - 04-25-09 13:11

33, Do not delay EKG in chest pain/ do not forget cardiac enzyme in chest pain due to acute coronary syndrome - cardiac chest pain

34. do not forget cxr in cardiac chest pain even if ekg says st elevation mi because if there is mediastinal widening and aortic dissection and you start alteplase without seeing cxr ,you will kill the patient in real life and fail ccs in that case if not whole test.

35. Do not forget - to obtain Urine drug screen cardiac enzyme in Panic attack - do not forget reassurance of the patient otherwise pt will be hyperventilating.

36. Give alprazolam sublingually in panic attack in css exam/ you may do tsh abg lipid profile in panic attack but it is not a must. You can give ssri for recurrent attack/ you may do depression index in panic attack but it is not a must.

37. Rash in a child is mostly viral / do not give antibiotic in a rash in a child unless you consider meningitis rash or rash of bacterial endocarditis

38. differenciate infant's rash from fifth disease which is actually parvo virus 19-/measles/meningitis/roseola infantum /rubella

39. do not order order MRI OR CXR IN FIRST TIME COMER for back ache /treat with NSAID- if comes again

38. If radiculopathy or neuro deficit or recurrent pain go with MRI

39. With radiculopathy or neuro deficit your DD are Cauda equina syndrome, Compression fracture,Facet joint degenerative disease of course lumbar disc herniation,spinal stenosis,tumour involving the spine causing radiculopathy.

40. Lumbar disc herniation ; give nsaid rest at home initially followed by physiotherapy follow up in two week and orthopedic surgery consult if conservative therapy fails/In Usmle and ccs do not admit the case of lumbar disc herniation

41. Consult is good thing but do not do at first visit --do orthopedic surgery consult if conservative treatment fail or if there is gross invovement of nerve roots or neurological deficit

42. If back pain exam there is radiculopathy, decrease lumbar spine mobility due to pain,straight leg raising test positive or crossed straight leg sign positive your diagnosis for ccs is lumbar disc herniation
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* Re:Yubraj 'sgolden rules for ccs- plus to musa
#1724766
bobby101 - 04/16/09 21:04

please do not comment here till I complete 100 rules. That is a request only you may overide it.
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* Re:Yubraj 'sgolden rules for ccs- plus to musa
#1726610
bobby101 - 04/18/09 19:37

43. If there is radiculopathy and neuro deficit then it could be an emergency like cauda equina syndrome or spinal metastasis compressing the nerve or trauma-- pt needs stat prednisolone and neuro consult sometimes oncology consult and radiotherapy.

Sometimes deficit like ankle reflex absent and hallucis tendon weakness leading to dorsiflexion of big toes weakness may be just l5 s4 prolapse vertebral disc- lasegue sign

and knee reflex absent and numbness towards medial aspect of foot may be l4 and l5 prolapse vertebral disc

45.in back ache due to prostate ca metastasis do not forget to order plain xray or skeletal survey -- the key point here is osteosclerotic changes rather than osteoclastic.-- you can also do mri and bone scan

46. Never order bone scan in a suspected case of multiple myeloma because it will be waste of money and time because destruction or osteoclastic activity is so faster than osteoblastic activity that bone scan will not pick it. Bone scan picks only osteoblastic activities.

47. If you suspect osteomyelitis you can order MRI WHICH is VERY SENSITIVE AND SPECIFIC. Nobody will fault you to do plain xray in acute case but it will be useless because periostel reaction will not be picked for 10 days.

48 . Do not delay to start antibiotic in osteomyelitis case and staphylococcus is commonest - so start decloxacillin or nafcillin If you suspect MRSA USE VACOMYCIN or PSEDOMONAS then ciprofloxacin that is fluroquinolone as well as use ceftriaxone

49 bone biopsy and culture is also diagnostic test for osteomyelitis

50. You have to use antibiotic for six weeks for osteomyelitis - INCOMPLETE TREATMENT IS NO EXCUSE

51. Admit the case of osteomyelitis for inpatient treatment with IV Antibiotic.

(Everytime I will see the reply, will post more)

Re: CCS Golden Rules
bobby - 04-25-09 13:45

Thanks,just keep it going.

Re: CCS Golden Rules
bobby - 04-28-09 09:35

I found the continuation of the Golden Rules first posted by meduploader...so I am posting them here for the benefit of all.

52. sometimes ccs will combine two cases- say case of hypokalemia and then which turns out to be a conn's syndrome- you have to treat for hypokalemia with oral potassium gradually and investigate for conn's syndrome - you have to do ct abdomen and also renin and aldesterone level/aldesterone level will be high and renin will be normal or low/

- you have to start potassium sparing diuretics like spironolactone pt will start getting better/ ct probably will show a mass/then you have to do surgical consult for laproscopic surgery -/

= they will accept the patient for surgery/ you have to do preoperative work up for surgery with blood grouping and rh typing and also pt ptt inr/keep the pt npo for surgery start iv /and surgeon will operate and case will probably end.

53.sometimes they will give you copd with pneumonia- you have to obtain both set of work up - say cxr/ spirometry/abg/ and treat both at the same time- say antibiotic mostly ceftriaxone plus zithromax

- and for copd exacerbation - ipratropium and albuterol/ and solumedrol as steroid/ follow up pt with cxr and daily spirometry/give oxygen /if abg is very bad and patient is crashing you may have to intubate the patient.
-smoking cessation counselling is must/ you must give fluid to these patient. In Copd pt you have to send these patient with home oxygen if po2 at room air is less than 55 mm of hg.

-Also, you have to do serial or continuous pulse oxymetry while in hospital stay and give o2 accordingly to adjust fio2.

54. If you get a case of hyperkalemia - never forget to do cmp and cbp and above all ekg/if ekg changes give calcium carbontate /you can also give keyexlate also called resin which absorbs potassium or exchnage the potassium which is taken out from gi tract in the stool-- also can start insulin plus 5 percent dextrose also sodium bicarb -- also can give furosemide make sure pt is not dehydrated -- last resort dialysis

so golden rule is never forget ekg in hyperkalemia and hypokalemia

55. never forget to do abg and pulse oximetry in SOB-DYSPNEA AND Shortness of breath

56. never forget to do proBNP -which is natriuretic protein- which will be raised in heart failure- and give lasix in that case

57. Dyspnea in exertion use of more than two pillows night time gasping for breath dyspnea in rest may be a sign of heart failure - Jvp raised basal crackles hepatomegaly hepatojugular reflux peripheral edema al are sign of heart failure-- do abg and pulse oximetry / but even if there is hypoxia do not intubate before you give lasix - by giving lasix pt drastically gets better
monitor pulse oximetry you will be happy on the improvement. LIKELIHOOD THAT PT WILL NEED INTUBATION.

58. Never forget mammogram after 40/ pap/ and bone scan after 50 in a lady who come for health maintainance exam-

59. osteoporosis case may be combined with fracture - give calcium vitamin d and alendronate -and refer to orthopedics for fixation if necessary.

60. Never forget to obtain hemoglobin A1C in diabetic . It speaks about glucose control in past three month in a diabetic patient,

61. Essential hypertension should be differentiated from other hypertension in young

- very young girl with wide spaced nipple streak ovaries cystic hygroma may have coarctation of aorta as the cause of hypertension

-young lady with hypertension may have cystic fibroplasia -do mri mra

-cold intolerance hair loss constipation brady cardia indicate hypothyroidism- usually hypertension will be diastolic obtain tsh then if increased obtain t4 and do thyroid scan which will show reduced uptake showing cold spots

-palpitation pyrexia like pressure lke headache paroxysmal hypertension in young population suggest phaeochromocytoma - obtain 24 hour catacholamine urinary metanephrine serum VMA All will be in higher side.

hot intolerance palpitation pyrexia like excessive sweating will indicate hyperthyroidism which may suggest hyperthyroidism/ obtain tsh which will be low and t4 which will be high-- hypertension will be the systolic type.

- hypertension with hypokalemia metabolic alkalosis -suspect hyperaldestreoinism primary also called conn's syndrome - do aldesterone level whic will be high and renin level which will be low. - do ct which may show adenoma you need to do surgical consult and lap adrenelectomy.

renal artery stenosis - suspect in refractory hypertensive do mri mra - do not give lisinopril in bilateral renal artery stenosis

cushing's disease also present with hypertension .see clue like easy bruising, cushigoid moon shaped face buffalo hump etc and obtain serum and urine cortisol and do dexamethasone suppression test

62. In hypertension cases- monitor pt in continuous cuff when admitted

63. If renal hypertension you will see lots of proteinuria and you do 24 hour urinary protein

64. there can be hypertension in scleroderma also a s well as polyarteritis nodosa

65. do not forget about office visit white coat hypertension

66. Interestingly, in pregnancy induced hypertension, you do also uric acid and fibrinogen level in addition to other test.

66. Alcohol can cause hypertension /also acute pain can cause hypertension

67. Essential hypertension is treated with weight manangement lisinopril or hydrocholthiazide low sodium diet

68. Always see the physical exam if you get no clue in diagnosis in th history part

69 pneumonia in young 3 yday old- do cbc which will show increse wbc count do randomblood glucose
do cxr which may show infiltrate
do blood culture
do viral culture
do abg -it may show hypoxia

give oxygen
give fluid because hypoxic child is dehydrated
if too much hypoxia may need oxygen by oxyhood -incresing fi02 -respiratory and hemodynamic support

sometimes bronchoscopy may be needed

Group b gbs is coomonest cause of pnemonia in this age group - treat with ampicillin gentamycin in this age group.

-you must follow up the case - initially forty eight hours after discharge in pneumonia.

70. If you get a murmur in a child do a cardiology consult -- it may be PDA -CONTINUOUS machinary murmur in 2 nd intercostal space - You may have to give indomethacin for its closure

71. if you get cyanosis in first day in a child give oxygen do pulse oxymetry ABG and consult cardiologist this is a case of transposition of great vessel - which will show egg shaped silhoutte of heat border.

72. Commonest congenital defect in a child is ventricular septal defect -consult cardiologist -may close by itself if not surgery

73. Bulging fontanellee and a fussy child is meningitis

74 - do all investigation -- cbc cmp culture lumbar puncture ct scan and cxr abg urine cs viral PCR- usaully you may forget viral PCR [ LIKE ME]

78 admit to icu -give iv antibiotic.GEl ARE the cause of meningitis G-group B GBS ecoli listeria monocytogenes

79. give ampicillin and ceftriaxone and continue SAMEantibiotic if sensitive, if positive with strep pneumonia /continue antibiotic for 10 to 14 days in younger kid/do not forget to give iv fluid

80. so meningitis a case with fever you have to do pan culture / do not forget urine culture and ua which is a important test -also do not forget lumbar puncture in meningitis - diagnostic test
and of course do ct before lp preferably.