CCS synopsis

PREPARED BY SANTOSH DHUNGANA

CCS synopsis.

First always see the sex and age of the patient, and keep in mind all the preventive aspects you are going to prescribe for him at the end, like vaccines and cancer screening, besides the no smoking, alcohol, drugs, safe sex, seat belt, medication compliance, medication side effect and patient counseling that we prescribe for all patients.

- Iv access

- Iv NSS

- Pulse oxy

- O2 inhalation at 4-6 l/min

- Cardiac monitoring

- Bp monitoring

- Admit to floors

- Vitals q 4-6 hrs

- Output msmt in all admitted patients, with Foleys if in ICU, or if complete bed rest is advised

- Bed rest

- Pneumatic compression stockings

- Don’t forget to examine the pt every day if he is in wards, and every 4-6 hrs if in ICU

- Neurochecks q2-4 hrs, for SAH, trauma, poisoning, etc, ie almost anybody in ICU

- Npo

- Cbc

- Bmp

- Don’t forget daily cbc/bmp for patients in ward, and every 4-6hrs for those in ICU

- UA

- HCG in all females

- Cxr

- Counsel patient

- Educate patient

- Safe sex counselling

- Seat belt

- Stop alcohol

- Stop smoking

- Stop illegal drugs

- Medication compliance

- Medication side effects

- Pap smear

- Fasting lipid

- DEXA scan

- FOBT

- Sigmoidoscopy, flexible

- Colonoscopy

- Mammogram

- Influenza and pneumo vacccine in elderly

- Vaccinations in child: DTP, polio, pneumo, influenza, varicella in >12 yrs

- Counsel parents

- Educate parents

- Home safety instructions

- Fasting lipid, lipid profile

- Fingerstick glucose in those in coma or with DKA- and not BMP, as it takes 20 min for reporting.

- BT has to be ordered separately, and doesn’t come with coagulation profile.

- Inall pts on heparin, PTT q6h; in pts on warfarin PT q1day till therapeutic INR is reached, then discharge home, and PT twice weekly is needed. Do baseline PT/PTT and FOBT before starting any of those.

- Don’t forget interval hx and c/e in pts in theward- every day, if in ICU, every 6 hrs or so. Use your judgement. Also don’t forget to monitor daily CBC/BMP for patients in the ward.

- H &H means Hb and HCT- in all actively bleeding patients, like splenic trauma, AAA, neonatal jaundice, G6PD acute hemolysis, etc.

- Treatment of severe mania- start with haloperidol, then olanzapine or risperidone with lithium.

- Use RL and not NS in patients with shock and acidosis. Use D5 ¼ NS in infants and children for maintenance fluid while NPO.

- Lead poisoning- don’t forget lead abatement agency or home lead paint assay, erythrocyte porphyrin, blood lead levels, calcium and iron supplement which will decrease absorption of lead, and succimer as DOC, use only behave modification if blood lead level <45,>45 and 2 drugs if >65, use docusate initially if constipation, parent education, do iron profile if pt has anemia, continue chelation therapy for 3 wks only, orally.

- Pregnancy- do BT, PTT, PT, Pap, TVS, HBsAg, HIV, RPR, TORCH, blood grouping and cross matching, DirectCoombs ifRh-, repeat in 24-28 wks if initially negative, Rubella Ab, Chlamydia and Gonorrhea cervical culture, urine R/M and C/S, counseling-pregnancy, counseling-breastfeeding in 2/3 trimester, 50gm OGTT in 24-28 wks, iron, folic acid, calcium after first trimester, flu shot in 2/3 trimester, exercise, high fiber diet,

- Alzheimers- TFT, B12, Folic acid level serum, Olanzapine for agitation (haloperidol not good in elderly), buspirone for anxiety, SSRI for depression, Temazepam for sleep problem (short acting Triazolam causes confusion),Donepezil,

- Very imp in elderly with Alzheimer’s- Advance Directives, Safety plan, Supportive care(consult social services),counsel pt- no driving

- Also in all elderly- flu vax, pneumovax, lipid profile, FOBT, DRE and PSA, colonoscopy

- HIV testing, ELISA in those with STD or multiple partners

- Ulcerative colitis- dx is by colonoscopy and biopsy, with GI consult. Give loperamide and dicyclomine for diarrhea along with disease modifying drugs.

- Irritable bowel syndrome- do TSH, FOBT, ESR, stool R/M, c/s, 72 hr fecal fat and lactose breath hydrogen test. Order lactose free diet, high fiber diet, avoid caffeine, relaxation technique, biofeedback, reassurance, dietary counseling, loperamide for diarrhea, psyllium(Metamucil) for constipation

- Depression- don’t forget TSH, psych consult, suicide contract, patient education, and1-2wkly f/u initially after starting SSRI. Use lorazepam initially for insomnia then withdraw.

- Mania- do urine toxicology screen, suicidal contract, psychotherapy (consult psychiatry), olanzapine or risperidone with lithium.

- Any malignancy diagnosis- CT head/chest/abdomen/pelvis as per need for staging, consult oncology, consult surgery, counsel cancer diagnosis, skeletal survey.

- Serum amylase and lipase in all abd pain- also urine, USG abd, LFT, AXR, Pt/PTT and NPO for immediate surgery can be needed, FOBT, HCg infemale, morphine with phenergan, consult surgery,

- In DKA- ABG, ketone level, serum osmolality, infection screen with CXR, urine and blood c/s

- Babies with resp bronchiolitis- sucition q1h, epinephrine and albuterol nebulisation, RSV antigen, chest physio, cardiac monitor, humidified oxygen, infant Tylenol

- Dexamet in Croup, and epinephrine if severe only.

- In septic arthritis (which can be gonococcal), do c/s of urethra, rectum, throat, blood, joint.

- All patients who come with chest pain, first give aspirin and sl nitroglycerine to all, in case there is coronary spasm.

- Pericarditis- ANA, RA, HIV, PPD, don’t tap even if fluid seen on Echo unless there is tamponade, NSAIDs and don’t use routine steroids.

- Low salt diet, low fat, diet in those with high lipids/ HTN

- Exercise program in obese, DM, HTN

- In almost all pts admitted to ward, think about vitals q4h, iv access, cardiac monitor in most, urine output, diet (normal or low sodium) and ambulation (at will) or bed rest with or without bathroom privileges.

- In ICU settings, elevate head end to prevent aspiration, vitals q2hrs, urine output q4hrs, pulse oximetry q 4 hrs, check cardiac monitor, check BP monitor q 4 hrs, pneumatic compression stockings, heparin q6hrs, npo, omeprazole or ranitidine iv for all

- Unconscious patients- fingerstick glucose test, 50%D with thiamine and naloxone cocktail in all, check airway first, suction airway (eg in narcotic overdose), blood alcohol and urine toxicology screen, CXR for aspiration,CT head as needed, charcoal if needed, NG with ETT and lavage as per needed, Suicide contract and Psych consult.

- Counsel for safe sex and contraception in all female, and all get PAP.

- CF patient- sputum Gram stain and culture, sinus XR, sweat chloride, 72 hr fecal fat, blood culture if needed, albuterol, chest physio, multivitamins due to malabsorption, influenza vaccine, pneumovax, consultdietitian,genetic counseling, pancreatic enzymes oral, high protein and high calorie diet,

- Accucheck at home for DM, Diabetic education,Diabetic foot care counseling,Diabetic diet, Exercise and wt reduction, medication compliance and mediaction s/e for DM

- HBA1C for DM when in hospital. Sliding scale insulin if admitted for severe infection, and stop metformin to prevent lactic acidosis.

- Examine extremities for DVT and swelling, and HEENT for LN, and rectal exam for occult blood in almost all cases.

- Dexamet prior to Antibiotics in pts with meningitis.

- Type’ obtain consent for procedure’ to get consent for certain procedures.

- surgeries, tube thoracostomy, thoracotomy, depression, suicide attempt, drug overdose, cardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eye procedures, ENT stuff, EGD, Colonoscopy – get appropriate consults

- VERY IMP ( you can do this only on 5 min screen) • enter follow-up tests at a later date i.e; following drug toxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INR monitoring etc), following disease activity ( follow up TSH etc)

- Enter elective screening tests for a LATER date in an inpatient i.e; colonoscopy, pap smear, mammogram ,Enter age appropriate and disease appropriate vaccines if not entered before

- In all patients in the ICU, order bed rest, Foleys, pneumatic compression, urine output, omeprazole, npo, cardiac monitor, bp monitor, o sat q 2hrly, vitals q2h, cbc/bmp daily in most patients, and swan ganz in pts with pericardial tamponade, myo infarction, etc.

- pregnancy with UTI- should check for pregnancy before initiating antibiotics for UTI. All pregnant women should be sent for urine culture, Chlamydia and GC culture, and pap smear. After treatment of UTI, usu with 7d of amoxy, always do repeat CS to document eradication. When such patient comes to office, send ua and hcg, then f/u after 30 min. ua will show uti. Send home on antibiotics, prenatal vitamins and f/u in 2 wks, and send for urine culture. Do repeat cs after the pt comes in 2 wks.

- Pt with dyspepsis- if alarm symptoms or if age more than 50, do EGD with biopsy.

- Type only ‘counsel’ or vaccine or synovial fluid analysis, and then press control and select multiple entries. Also works for blood culture and gram and fungal stain, csf, arthrocentesis, etc.

- HUS: Supportive theray as initial choice ,Monitor CBC and BMP , If Clinical picture worsens, get plasmapheresis ,If BMP worsens, get HD

- CCF patient: cardiac enzymes, ABG, shift to ICU, telemetry, elevate head, lasix, low Na diet, output monitor, fluid restriction, daily wt, heparin, kcl, digoxin, enalapril, metoprolol, morphine, daily BMP, consult cardiology, pepcid continuous, ETT if patient desaturates, lastly after discharge Cardiac Rehabilitation Program.

- PCOD: estrogen, DHEAS, androstenedione, LH, FSH, testosterone, prolactin, TSH, urine cortisol and urine 17 ketosteroids to rule out CAH, TVS, OGTT, lipid profile, exercise, metformin,wt loss, OCP, low fat diet,

- Postmenopausal: pap, DEXA, mammo, lipid, FOBT, colonoscopy, glucose; HRT for hot flashes, or estrogen vaginal cream, diet-calcium enriched, exercise very imp, stopping smoking v imp, counseling-HRT (order if pt is on HRT),

- Pt with fatigue or weaknes: PPD, HIV, ESR, FOBT, EKG, CXR, GTT,

- Rhabdomyolysis: monitor BMP esp K and Ca, Mg, PO4, uric acid and CPK every 12 hrs or so. Alkalinise urine with NaHCO3 and monitor urine pH till its >6.5, use NS to increase urine output to >300ml/hr, start half NS and mannitol after urine output has been established.

- PTB: don’t forget to do optho consult and LFT before starting DOTS, and don’t forget B6 with INH. f/u with sputum and CXR. Also do LFT on f/u. When the patient comes with symptoms of TB, there is no use of doing PPD- its done only for detecting latent TB.

- Do blood c/s in acute prostatitis, and treat with oral cotrim or cipro if mild, or admit and treat with ampi and genta if severe infection with sepsis.

- Pleural effusion: do coagulation/bleeding profile and Decubitus CXR(layering of 1cm is needed to tap) before tapping. Draw serum LDH and protein at the same time when sending pleural fluid for analysis. Do ANA, RA if no cause can be found for effusion. If positive, do Rheum consult. If ANA is positive, only then confirm with dsDNA. If pH of parapneumonic effusion is <7.2,>

- Sickle cell with Acute Chest syndrome: do sputum and blood culture, type and crossmatch blood in case transfusion is needed, iv morphine and phenergan for pain, D5 ¼ Ns for hydration, iv cefuroxime or xone plus azithro, incentive spirometry, chest physio, albuterol nebulisation, exchange transfusion may be needed (esp if sickling crisis like priapism and stroke), H&H q4h. On discharge, penicillin V oral prophylaxis, pneumovax, flu shot, and hydroxyurea can be given to decrease the acute crises frequency.

- Anaphylaxis: give all of these- ranitidine, diphenhydramine, epinephrine sc if mild or iv if severe( first thing to order should be this), albuterol and hydrocortisone. Later, dopamine in ICU if the BP doesn’t come up. Consult Allergy and Immunology. Medical alert bracelet and counsel- avoid allergen. RAST can be done too. If pt is already on beta blocker, then epinephrine maynot work, so give glucagon before epinephrine to neutralize the beta blocker.

- Panic attack: urine toxicology, ECG, cardiac enzymes and TSH are imp; rebreathing in a bag, alprax, reassurance, psych consult only if recurrent for cognitive behavioral therapy, SSRI if recurrent (ie panic disorder), avoid caffeine, nicotine and alcohol.

- CRF: treat hyperkalemia with all of the following- calcium gluconate, NaHCO3, 50%D with insulin, kayexalate, salbutamol; do iron studies to confirm ACD, then start EPO, control HTN with ACEI if mild RF and CCB if severe, renal diet (low Na, low K and low PO4), use calcium acetate as PO4 binder if PO4 is high, consult nephrology

- Osteoporotic Vertebral fracture: ESR is imp to rule out other pathology, do XR and MRI if s/s of compression of nerves are present, SPEP/CXR/mammo to rule out mets, DEXA, TSH to rule out hyperthyroidism induced osteoporosis. IF its postmenopausal, then all fragility fractures warrant alendronate or raloxifen (biphosphonates preferred) in addition to vitamin D and calcium supplement.

- Toxic Shock syndrome: order tampon removal stat, do sepsis workup like blood and urine culture, CXR protable AP, ABG, Coagulation profile to rule out DIC; then start Clindamycin which is the DOC as it directly inhibits toxin production, start Dopamine if BP is low. Discharge the patient on oral Clinda after his condition improves. There can be pancytopenia, hypocalcemia and hypoalbuminemia on lab studies.

- Order TVS in all gynobs cases, even if virgin or if placenta previa too!

- Temporal Arteritis with PMR: do Ct head to rule out other causes, Baseline DEXa before starting steroids, CXR to rule out thoracic aneurysm as this is common in GCA patients re! Put patient on PPI, calcium and vitamin D while starting steroid.

- leaking AAA: stop metoprolol and aspirin if the pt is already on it. If unstable(eg SBP <90),>

- Intussusception: don’t forget pediatric surgery consult before enema, morphine for pain, NG decompression of stomach, and USG for diagnosis.

- Sinusitis: naphazoline intranasal or pseudoephedrine po.

- Alcoholic withdrawl seizure- iv lorazepam, oral chlordiazepoxide (Librium) only after the pt’s consciousness improves, glucose with thiamine, folic acid, soft restraint, elevate head, serum Mag and PO4 (and supplement both after results come), LFT, coagulation (vit K if deranged), ABG, urine toxicology and blood alcohol level (repeat daily till normal), CXR for aspiration, haloperidol for agitation, consult substance abuse unit, neurocheck q 2h, seizure precautions, ETT if Osat deteriorates. Lastly before discharge, alcohol rehab and Alcoholics anonymous, and psych consult (may be suicidal).

- Do direct coomb’s in all pregnant ladies with blood group O.

- Nephrotic syndrome in child- lipid profile, 24 hr urine protein estimation, complement level (c3, c4, CH50), albumin infusion f/by lasix for ascites (can be repeated next day), coagulation profile, renal USG, low Na and high protein diet, daily wt, output msmt, Nephrology consult, repeat BMP everyday, pneumovax, Meningo and HI vaccine also if feasible

- In all babies- after discharge, counsel parent, counsel breast feeding,counsel safety plan, vaccine

- HTN patient- repeat BP msmt in 2 followup before labeling as HTN, do investigations in the meantime, like lipid profile; start HCTZ, stop smoking/alcohol, wt reduction, low salt diet, low fat diet, exercise

- Turner: do TVS to see streak gonads even in virgins, karyotype, FSH, LH, estrogen, TSH, prolactin, blood sugar, lipids, LFT,skeletal survey to see other anomaly, renal USG, Echo, TSH, Audiometry, Ophthalmo consult, consult dietitian, consult obsgyn, consult genetic, consult psychiatry for IQ determination,

- Child abuse: skeletal survey very important, coagulation study, BT has to be ordered separately, bone scan for fractures, ophthalmo consult, CPS consult, psychiatry consult, LFT/Pan enzymes for abd trauma, USG abd, Urinalysis, Stool R/M , FOBT, CT head if symptomatic.

- PE: aspirin as in all chest pain cases, avoid nitroglycerine though as these patients have hypotension, cardiac enzymes, portable CXR stat AP, ABG, coagulation profile, cardiac enzymes, FOBT, VQ as it is faster than CT, D dimer stat, cardiac/BP/oximetry monitoring q1-2h, PTT q6h after starting heparin, PT q24h after starting warfarin, heparin for 5 days, start warfarin in second day, stop heparin after INR is therapeutic, send home and do INR monitoring twice weekly, Plt count on day 3 to rule out HIT

- SAH: ICU, neurocheck q1h, consult neurosx, 4 vessel cranial angiogram, BMP q24h to rule out electrolyte anomaly, docusate, nimodipine, omeprazole as in all ICU patients, Percocet or ketorolac or tramadol for pain( morphine causes constipation), water restriction if hyponatremia, followed by NS infusion, iv labetalol if malig HTN, ventriculostomy if hydrocephalus develops.

- Febrile Neutropenia- avoid DRE as it can cause mucosal injury and introduce organism into the blood, culture urine, stool, catheter tip, blood, CSF (not in all), sputum; empiric treatment with ceftazidime or piperacillin/tazo/gentamicin; GCSF only if ANC <100;>

- Infective endocarditis in drug user: TEE better, blood culture 3 times 10 min apart (advance clock and order), order urine toxicology, HBV/HCV serology, HIV ELISA, central line placement for antibiotic, start vancomycin and gentamycin presuming its Staph, continue vanco for 6 wks, and stop genta after 5 days (if non drug user, start xone and genta- continue xone for 4 wks and genta for 2 wks if viridians, both for 6 wks if Enterococcus).Always reconfirm eradication by repeat blood culture. Can also order blood antibiotic level to see if MBC is reached or not.

- Graves: 24 hour RAIU scan for diagnosis, TSI antibody, control with ppnl and PTU or methimazole for 4 weeks, then stop methimazole for a few days to increase RAI uptake, then do RAI ablation therapy once (order, RI, once), then again start ppnl and PTU to prevent flares during RI therapy, steroids to prevent progression of opthalmopathy with RI if pt has signs of eye disease. f//u in 4 wks with T4 (not TSH re), can repeat second dose of RI if still hyperthyroid. Do baseline CBC and LFT before starting the patient on PTU.

- Lung Ca- sputum cytology, HRCT chest, consult pulmonary medicine for bronchoscopy, CT guided transthoracic biopsy, Pul function test, CT chest/abd/head and bone scan for staging, LFT, consult surgery and oncology and radiotherapy.

- Ovarian Ca- CT chest/abd and mammogram to rule out Krukenberg, Pap, CA 125, ascetic fluid tap, endoscopy if needed, endomet biopsy if needed, colonoscopy if FOBT+, consult obgyn and oncology.

- Meningitis- take blood culture, advance clock 1 min, then start antibiotics, do LP then (antibiotics don’t affect LP), CT needed before LP only if pt is obtunded or has FND, else there is no need, coagulation profile for DIC, interim hx and examination q4h till patient improves, then q12h.

- AF- IF Pt come to ER with acute AF, diltiazem iv is the DOC to control the acute symptoms, followed by oral diltiazem after the heart rate drops to 80; digoxin can be used but only for maintenance, the loading dose of digoxin for acute symptom control is a thing of the past, because of the fast action of diltiazem compared to digoxin.

- AF- also do TSH, ECG, cardiac enzymes, urine toxicology, ECHo, cardiac consult, coagulation profile, heparin and warfarin after one day, PTT monitoring q6h while on heparin, and PT q24 hr while on warfarin, after INR is reached, discharge and follow up in anticoagulation clinic with INR twice weekly.

- AF of less than 48 hrs can be cardioverted with amiodarone or dofetilide or synchronized cardioversion under heparin cover,and then discharged from ER itself, but if longer duration AF, then we need 4-6 wks anticoagulation with warfarin before cardioversion, and we have to admit the patient. Cardioversion is preferred to rate control in those with acute coronary syndrome, heart failure or hemodynamic instability.

- Pericardial tamponade: swan ganz catheter for monitoring, CTVS consult before pericardiocentesis, send pericardial fluid for tests, ABG, ECHO, a catheter may be placed after centesis, and thoracotomy might be needed if patient is unstable or centesis doesn’t work. Do repeat CXR and ECHO for reaccumulation after 24 hrs.

- Pancreatitis- if febrile and has developed abscess, order CT, CT guided aspiration and culture, debridement or percut drainage, imipenem, TPN.

- Pseuocysts <6cm>

- UGIB- monitor Ca and Pt with multiple transfusion, may need FFP if INR is raised. In EGD, clean base ulcer- can be discharged within 24 hr, if clots present, keep for 2-3 days, if visible vessels or if bleeding, apply local epi, and admit for longer in ICU. After pt is sent home on PPI, repeat EGD and biopsy after 4-8 weeks for gastric ulcer, no need for DU.

- Order postural vitals in GI bleeding.

- LGIB- do colon preparation with polyethylene glycol before doing colonoscopy,

- All DM patients- on hospitalization, stop OHA, start insulin with 4-6 hrly accucheck.

- start statin directly after LFT if patient has high LDL but is unlikely to respond to diet and exercise due to multiple risk factors;

- HIV positive on ELISA- don’t forget to do western blot, CD4 count, PCR for viral load before starting HAART, VDRL, HBsAg, HCV RNA, Toxoplasma serology, pap smear, flu vaccine, pneumovax, HIV support group, PPD, LFT before starting HAART

- All patients with anemia- do iron studies, even if there is an apparent cause for it.

- All patient with hyperCa- PTH level, SPEP,, CXR, USG or CT abdomen to see for tumor, Alp to see bone formation, bone scan to see for mets.

- Pt with HTN, hypokalemia and leg cramps- do plasma renin activity, plasma aldosterone:renin ratio, spironolactone, do CT, then surgery consult and adrenalectomy if required.

- DKA - Initial Tx is Regular Insulin + IV NSS (0.9%) + KCL + accucheck 1 hrly, S.K 2 hrly and ABG 2 hrly and gradually increased to 4 hrly. Once the Glucose level is 250, change the IV fluid to D5+0.45%Saline (rest conintue). Now once the pt is no more vomiting and ABG is <>

- in all pts with polytrauma, order C spine immobilization before doing any examinations. ABG in all to rule out lactic acidosis. Blood ethanol level and urine toxicology in almost all MVA patients. Spine, Chest, Pelvic XR in almost all- including abd CT (preferred over USG if the patient is stable) and head CT if symptoms so dictate. Cardiac and BP monitor, Foleys and urine output measurement, ICu admission, iv morphine with iv phenergan, and order H and H (ie serial hb and hct) in those with suspected intracorporal bleeding. LFT, amylase and lipase if associated abdominal injury. NPO in case surgery is needed, and blood crossmatch in case transfusion is needed. Cancel C spine immobilization once the XRs clear the spine.

- Any pt comes with unconsciousness, fingerstick glucose is a must (its fast than bmp), 50%glucose, with thiamine iv, and naloxone iv are also indicated. Aspiration precautions, neurocheck q2hrs, etc

- In all pts with abd pain, don’t forget lipase, amylase, urine analysis, usg abd, axr, lft.