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 the
m NPO
5.All NPO patients must also have their urine output measured (type "urine outpu
t")
6.If a woman is between 12 and 52 years old and there is no mention of a very re
cent 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 (i
f 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 A
ccuchecks.
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 saturati
ons), 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 "suicid
e 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 i
n case they have to go to the O.R.)
17.In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibod
y Screen"
18.In any patient with excess bleeding (especially GI bleeding), type "no aspiri
n" 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 treatme
nt 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 "fingerstic
k glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urin
e 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-in
duced 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 tera
togens, 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
31.Don't forget about patient comfort! Treat pain with IV morphine, nausea with
IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomn
ia with PO temazepam
32.All ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidin
e
33.If you put a patient on complete bed rest (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 dehydra
tion, hypovolemia, or fluid overload), place a Foley catheter and order "urine o
utput"
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" (ot
herwise 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 f
luid analysis separately (it is not automatic). If you don't order anything on t
he 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 addit
ion to IV normal saline and thiamine

42.All patients over 50 with no history of FOBT or colonoscopy should get a rect
al exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43.All women > 40 years old should get a yearly clinical breast exam and mammogr
am (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 st
atus, type "medical alert bracelet" upon D/C
47.Any patient with diarrhea should have their stool checked for "ova and parasi
tes", "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 L
FTs)
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, b
ood type and crossmatch, analgesia, PT, PTT, pneumatic compression stockings, Foley
utput, 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 Alzheimers, first rule out other causes. Order a CT head, vitamin
B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, i
f 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. I
n 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 f
ood can stimulate the pancreas
60.Send patients home on a disease-specific diet: diabetics get a diabetic diet, h
ypertensives get a low salt diet, irritable bowel patients get a high fiber diet, he
patic failure patients get low protein diet, etc
61.Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable
angina
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 abou
t compliance
64.In any patient who presents with an unprotected airway (as in overdoses, coma
toses), get a CXR to rule out aspiration
65.In any patient with one sexually transmitted disease (such as Trichomonas), c
heck 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 TRIP
LE 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, vagina
l pH, cervical gonococcal, chlamydia culture
70.If a woman is found to have vaginal candida, check her fasting glucose
71.All suspected child abuse patients should be admitted and you should order TH
REE consults: consult child protection services, consult ophthalmology (to look for
retinal hemorrhages), consult psychiatrist (to examine the family dynamics)
72.When a woman reaches her menopause, she should have a fasting lipid profile che
cked (because without estrogen, LDL will rise and the HDL will drop), a DEXA sca
n (for baseline bone density), FOBT and colonoscopy (if she is over 50)
73.When the 5 minute warning screen is displayed, go through the following mnemo
nic:
Recreational drugs & Reassurance
Alcohol
Tobacco
Exercise
Diet of high protein, no lactose, low fat
Seat belt, Safety plan & Suicide precautions
Education
X for safe sex
74.If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 199; if ovarian cancer, order CA 125.
75.Remember to give phototherapy to a newborn with pathologic unconjugated bilirub
inemia (it is not helpful if it is predominantly conjugated). Also, with phototh
erapy, keep the neonate on IV fluids (the heat can dehydrate them), and give ery
thromycin 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, u
rine culture, sputum culture, and even CSF culture. And give antibiotics to cover EVE
RYTHING.

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 dimercapro
l 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 pred
nisone.
82.If any patient has cancer, get an oncology consult.
83.In a patient with rapid atrial fibrillation, decrease heart rate first. Then
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 t
he patient NPO, give IV fluids (if necessary) and order polyethylene glycol.
87.Any patient with Mobitz II or complete heart block gets an immediate transcuta
neous pacemaker. Then order a cardiology consult to implant a transvenous pacemake
r
88.If calcium level is abnormal, order a serum magnesium, serum phosphorus, and PTH
89.Treat both malignant hyperthermia and neuroleptic malignant syndrome with dant
rolene
90.All splenectomy patients get a pneumovax, an influenza vaccine, and a hemophilus va
ccine 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 (follow optic neuritis
)
94.If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well a
s a peripheral blood sample for: LDH and protein (to help differentiate a transu
date 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 s
kin test for allergens (to help prevent future disasters) and consult an allergis
t
97.Do not give cephalosporins to any patient with anaphylactic penicillin allerg
ies (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 TS
H, and finger stick glucose
100.All renal failure patients get: nephrology consult, calcium acetate (to decrease
the phosphorus levels), calcium supplement, and erythropoietin.

Step by step guide to CCS cases: I don t know if this has been posted before, I
found it on the net and it should make the CCS cases easier to approach.
Select

Start Case button to begin.

You will see the case introduction. Wait! Note on the erasable board:
Setting
Age of the patient
Race of the Patient
Sex of the patient
Then click OK and you will see the initial vital signs. Wait! Note on the eras
able board:
Stable or unstable?
Then click OK and you will see the initial history. Wait! Think and write on t
he erasable board:
Differential Diagnosis :
Allergies
Habits smoking , alcohol , drugs , etc. Anything worrisome?
Then ask:
Is the patient stable or is it an emergency? A clue to this would be in the hist
ory - for emergency cases, you will see only the basic history of present illnes
s and not the detailed history (social, past, etc). All other history will be u
nobtainable .
If unstable, do a EMERGENT physical exam. No emergency case should get a full ph
ysical exam - it s an emergency!!
For the EMERGENT physical, choose the general appearance and the relevant syst
em. If needed, add one or two relevant systems.
After you note the results of the EMERGENT physical, stabilize patient immediate
ly:
Airway Intubation?
Breathing Oxygen mask? Chest tube?
Circulation IV fluids? Dopamine?
Drugs Naloxone? Dextrose? Thiamine?
IV Access?
Then ask:

Does the patient s condition correlate to the setting?

Emergency or unstable patient in office needs to go to the ER immediately!! Chan
ge location if necessary.
After the patient is stable and in the right setting, proceed to
w-up history and a more detailed RELEVANT physical exam.

Interval/follo

If the patient is already a stable case in the right setting, proceed straight t
o the RELEVANT physical exam.
Then ask:
Is the case limited to one particular system? Like Asthma or MI?
Choose the particular system and a few related systems, based on the most likely
diagnosis.
Is the case not limited to one particular system?
Choose a COMPLETE physical exam. This option is available on the top of the phys
ical exam choices. Examples of such cases include Case for Annual Physical Exam,
Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc.
Note the significant findings on the physical exam and go back to your erasable
paper and revise your Differential Diagnosis. Strike out those which are less li
kely and add those are more likely.
Then keeping the Differential Diagnosis in mind, consider the labs to be done.
When considering labs use this mnemonic:
I B U O P
I Imaging > X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.
B Blood > CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.
U Urine > Urinalysis, Toxicology Screen, Ketones, etc.
O Others > Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pu
lse Oximetry, Biopsies, etc.
P Pregnancy test > For any female of reproductive age presenting with abdominal o
r pelvic symptoms, or trauma.
When ordering labs, consider:
Is this test time-effective/time-consuming? Choose time-effective.
Is this test initial screening/confirmatory? Choose initial screening.
Is this test cheap/expensive? Choose cheap.
Is this test non-invasive/invasive? Choose non-invasive.
Then ask:

Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might s
atisfy the above criteria but will not tell you anything useful.
Are there any specific tests for this condition? Examples are Cardiac Enzymes fo
r MI, Sweat Chloride test for Cystic Fibrosis, etc.
Are the tests in the right order? Example Pulse Oximetry before ABG, CT before S
pinal Tap, etc.
Order the labs using the Order button.
Then advance clock to the Next Available Result .
Understand the results. Ask:
Is the diagnosis clear or do I need any confirmatory tests?
If diagnosis is clear, start treatment.
If confirmation is needed, order confirmatory tests and then start treatment.
Treatment :
Determine if the patient is in the right setting. If patient is in office and ne
eds to be admitted, change location to ward. If patient is in ward and is in a s
erious condition, change location to ICU.
If case is admitted, order:
IV access (unless IV drugs are not indicated) Type IV Access .
Vital Signs Type Vitals and click on
condition of patient.

Every 1,2, 4 or 6 hours depending on the

Activity Type Bed Rest and choose Complete bed rest or Bed rest with bathro
om privileges or type restrain and choose Restrain patient in bed .
Diet Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order Diet and you will see
the list of options, choose which is the best for this case.
Tubes NG Tube? Foley s catheter?
Fluids Saline, Ringer, etc. Type
case.

Fluids and choose which is the best for this

Urine output Type Urine Output and choose frequency. There is no option for In
put/output chart.
Medications :
Stop! Check for allergies on erasable board!
Order standard drugs for this case.
Decide IV or Oral. Decide bolus or continuous. Decide frequency.
Labs :

Additional labs to confirm diagnosis?

Labs to monitor? Cardiac Monitor? Pulse Oximetry?
Consults :
Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social wor
ker, etc.
Then move clock!
Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours
/12 hours/1 day/2 days/1 week.
Do Interval/follow-up history.
Understand the results of the labs.
Then ask:
Has the patient s condition changed significantly?
If yes, change locations.
If the condition has improved, move the patient to the next location in the orde
r ER --> ICU --> Ward --> Office/Home.
If the condition has worsened, move the patient to the next location in the orde
r Home/Office --> Ward/ER or Ward/ER --> ICU.
If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/
Home):
Stop unnecessary medications and change IV medications to oral.
Discontinue IV fluids.
Remove tubes.
Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant.
Patient education or counseling or diet specific and vital to this case. Type p
atient education and counsel and see if anything is relevant to this specific
case. Type Diet and see if anything is relevant to this specific case.
By this time, the 5 minute screen will appear!
Then type counsel and choose the relevant things. You can choose multiple thin
gs at a time. See your erasable board for any worrisome habits like alcohol or s
moking!
Type patient education and choose the relevant things. You can choose multiple
things at a time.
Patient education / Counseling options :
Every adult person - Drive with seat belt, Exercise program, No illegal drug use
.

Every person taking long-term medications - Medication compliance, Side effects

of medication.
Every person who takes alcohol - Limit or stop alcohol intake.
Every person who smokes - Smoking cessation.
Every person of reproductive capacity - Safe sex techniques.
Every person with long-term conditions, life-threatening allergies, chronic illn
esses - Medic Alert Bracelet.
Female requesting contraception or practicing unsafe sex - Birth control, Contra
ception, Safe sex techniques.
Cancer case - Cancer diagnosis.
Asthmatic - Asthma care, medication compliance.
Terminal case - Advance Directive (Family), Advance Directive (Patient) and Livi
ng will.
Every post-operative case - Deep breathing and coughing
Diabetic - Diabetic foot care, Home glucose monitoring, Diet.
Learning disorder kid - Educational remediation.
Osteoporosis - Estrogen replacement therapy.
HIV case - HIV support group, safe sex techniques.
Hypothyroidism or endocrine case - Hormone replacement therapy.
Lactose intolerance - Limit cow s milk intake, Diet.
GI bleeding, peptic ulcer case - No aspirin, Sit upright after meals.
Old age, epileptic, vision defects, narcolepsy - No driving.
Anxiety case - Relaxation techniques, Rebreathing into a paper bag.
Violent psychotic case - Restraining order.
Spousal Abuse - Safety plan.
IV drug use - No illegal drug use, SBE prophylaxis, Safe sex techniques, Stop al
cohol, Smoking cessation.
Pelvic surgery - No intercourse.
STD - Safe sex techniques, Sexual partner needs treatment.
Depression - Suicide contract.
Routine screening : Schedule appropriate screening tests as per age. Type the re
levant test and schedule.

Immunizations : For Pediatrics and Geriatrics as relevant. Type Vaccine , choos

e and schedule.
At the end of the 5 minutes:
Type the Final Diagnosis.
You are done!!!
For Kids: Add age appropriate vaxine.
Helmets when Bicycle riding.
water temp<120 degree.
Dental health.
GUn safety.
smoke detector.
Teenage : DOnt drink while drive counsel.
For every one add age appropriate SCREEN.UV protection .Postexposure prophylaxis
.
CANCER screen everyone gets it.
Females: think if she neeeds to be PAPed.
Chlamydia screen for a sexualy active with many.
Elderly geriatic *Mamograph if older.
*osteoporosis screen.
*pneumovax and flu vax for elderly.
*elderly fall prevention.
*Hormone replacement.
Screening :
Consider:
Self-breast exam every month after age 20.
Clinical breast exam every year after 40.
Mammography every year after 50 in normal-risk females.
Mammography every year after 40 in high-risk females.
Pap smear - every year (for 3 years) after 18 years or earlier if sexually activ
e. Then, every 3 years until 65.
FOBT every year after 50 + Sigmoidoscopy every 3 years after 50 years.
OR
Colonoscopy every 10 years after 50 years.
Digital Rectal Exam every year after 40.
PSA every year after 50.
Vaccines :
Geriatrics :
Pneumococcal vaccine once for every person above 65. High-risk patients get earl
ier.
Influenza vaccine every year for every person above 65. High-risk patients get e
arlier.

Pediatrics :
DTaP - 2 months, 4 months, 6 months, between 15 and 18 months, between 4 and 6 y
ears.
IPV - 2 months, 4 months, between 6 and 18 months, between 4 and 6 years.
Hepatitis B - Birth, 2 months, 4 months.
H. influenza B - 2 months, 4 months, 6 months, 12 to 15 months.
Pneumococcus - 2 months, 4 months, 6 months, 12 to 15 months.
Varicella - Between 12 and 15 months.
MMR - Between 12 and 18 months.