I HAVE DESIGNED A FRAMEWORK FOR CCS CASES BASED ON PREVIOUS FORUM MEMBERS FAMOUS MNEMONIC LEBTAC, WITH SOME MODIFICATION. NOTE THAT THIS IS JUST A FRAMEWORK TO GUIDE YOU THROUGH. WE FORGET TO ORDER INVESTIGATIONS WHICH ARE RELEVANT AND OBVIOUS, BUT SOMEHOW WITH THE STRESS OF EXAM.
HERE IT IS
LEBTAC
L-LOCATION-IMP TO NOTE WHERE THE PATIENT IS FOR STARTERS, READ THE HISTORY WITH SPECIAL EMPHASIS ON DRUGS, PAST MX AND ALLERGIES, SEE THE VITALS TO FORM A DIFFERENTIAL DIAGNOSIS AND WRITE IT DOWN …
IS THE PATIENT STABLE? CAN THE PATIENT BE MANGED IN OFFICE SETTING? DO I WANT TO CHANGE THE LOCATION? IF STABLE, DO A FOCUSED EXAMINATION.IF THE PATIENT IS IN A LOT OF DISTRESS AND THE VITALS ARE VERY UNSTABLE DO A FOCUSED EXAM TAKES 2-3 MIN OF CLOCK TIME BUT GIVES IMPORTANT CLUES EG MUFFLED HT SOUNDS OR TENSION PTX DO EMERGENT MEASURES TO RELIEVE AND THEN PROCEED FURTHER
DON'T FORGET INTERVAL Hx/ exam
TWO TIMES CLOCK AND SIMULATED TIME CLOCK TIME NOT SCORED
E-EMERGENCY ORDERS-Get in prompt Emergency Measures OR GET IN POEM
G-GLUCOSE FINGER STIX
E-EKG 12 LEAD
T-Treatments-NTD-Naloxone, Thiamine, Dextrose-Tubes-Suction, ETT, NGT, Foleys Catheter if in retention or dehydration-Needles-Needle Cricothyrodotomy, Needle Chest Decompression, Pericardiocentesis for tamponade
I-IVA, IV Fluids if patient needs bolus and bolus or cont
N-Neck immobilization- Trauma cases if the neck is not already immobilized
P-Pulse oxy/PEFR if needed
O-Oxygen
E-Elevate pt
M-Monitor Cardiac/BP/Pulse Oxy
B-BIL UPS-is for Routine Orders; BIL UPS is a framework which covers all the things which should come to our minds in day to day life. The logic is testing all the fluids, you will need this for most of the patients and it’s the time when BILLS GO HIGH. So send the bill via UPS…just for memory
BIL UPS
B-Bloods I am not going to list the bloods which are logical as CBC, BMP, LFTs but those we forget.
E-PACT- E pact between doc and pt, just for memory
E-ESR -we forget this often again do it only if needed else u will be penalized.
Electrolytes Mg, Ca, phosphate eg. Cardiac arrythmias
P-PT/PTT/INR esp for bleeding pat, pat on anticoagulants, preop patients/d-dimer if needed
A-ABG sounds silly but we do miss it sometimes, Alcohol levels
C-5 Cs, Imp Cardiac enzymes CK-MB stat and 8 hr, Trop I stat and 8 hr*2, CPK, CRP, Cross match for a bleeding patient, Complement Levels eg. Autoimmune diseases and GN
T-TFTs Thyroid function esp in AF, Tired all the time pts
I- IMAGING- be sensible order X rays CXR before V/Q scans, basic inv first, remember CXR is a part of sepsis work up
L-LIQUIDS- interesting one obvious Liquids or fluids so CSF, Pleural Fluid, Ascitic fluid, Joint Fluid, Obtain consent before these procedures
U-Urine Urine analysis, Urine culture and sens, Urine Toxicology, Cx gm stain, ph, wet mount, gonococcal and Chlamydia culture, PAP smear
P-PREGNANCY-Important to mention separately for it gets missed Pregnancy test Bhcg urine and blood eg appendicitis
S-Stool microscopy for ova and parasites, C&S, FOBT esp starting anticoagulants, C.diff Ag
T-TREATMENT
Treatments now this is where common sense prevails. So pain relief, stabilize the patient and then transfer to ward/ICU, Some high yield facts-Pain Killers-Analgesic Ladder-Tylenol, Perocet, Ketamine(Toradol) eg migraine, Meperidine (Biliary Colic), Morphine and Metoclopramide,
Antibiotics-Ampi and genta for Ac prostatitis, Floroqunolones on D/C eg Cipro
IV Ampi+ Genta for Ac Pyelonephritis inpat -also for Pyelonephritis in pregnancy
IVCeftriaxone+Azithromycin-Community Acquired Pneumonia –inpatient Rx
IV Vanc+Gent-Endocarditis
IV Ceftriazone+Vanc- Empiric for Bact Meningitis+/-Acyclovir for suspected H simplex meningitis, +/- Ampicillin elderly, immune comp
Oral Amoxy –Clav or TMP-SMX+MNZ-OP mgt of Ac Diverticulitis
IV Ampi+genta+MNZ -Acute Abdomen
TMP+SMX -Pneumocystis add Pred if PO2 <>
IVClindamycin -Cellulitis
IVCeftriazone+Doxy-in pat PID
IV Ceftazidime-neutropenia
Oral Amoxycillin-Otitis Media, Sinusitis
IV Amphotericin B + Oral Flucytosine for 14 DAYS fb Fluconazole orak 8-10 wk-Crptococcal meningitis
IV Ceftriaxone and Vancomycin-Septic joint empiric Rx
Rate control-AF-Metoprolol, Cardiazem (Diltiazem), Digoxin keep in mind C/I + anticoag> 48 hr
A-ADMIT
Admit to ward/ICU. Before admitting review the treatments STOP any unnecessary meds eg stop OCP in PE case, NSAID in peptic ulcer perf, AND then ADMIT, Compress (compression stockings, DVT prophylaxis), Protect (gastroprotection, PPI esp ICU) and Consult SPECIALIST
A-Activity
D-Diet NPO/Soft diet/Diabetic diet/Low sodium diet/Low fat diet/Stool softner in Elderly, SAH
M-Monitor- bloods Cardiac enz/amy/Lipase/Hb/Hct esp if UGI bleed or transfsn q6h/BMP/bld gases/Accuchek/INR/PT/PTT pts on heparin q6h, if patient improves switch oral meds, d/c ivf, cancel npo, wean off oxy, Interval history
I-Input/output/daily wt/Incentive Spirometry for Post OP pts/Rib #/Chest Trauma/Acute Chest Synd/Asp Pneumonia
T-Temp/Vitals q2h, q4h/Neurochecks/Telemetry
STOP/COMPRESS/PROTECT/CONSULT
Counsel, 5 min window if patient ready for d/c
Psychotherapy, Suicide Contract, Counsel-smoking cessation, diet, exercise, med compliance, safe sex, seat belt use, vaccination esp in Elderly exac COPD /children/preg/immunocompromise/sickle cell, substance abuse, Cardiac rehab post CHF, Diabetic counsel.
FINAL DIAGNOSIS AND END OF CASE
SUMMARY
D/D
L-Location
E-Emergency orders-get in prompt emergency measures-GET POEM-Glu, EKG,Treat-Tubes,Needles,NTD, Pulse oxy,Oxy,Elevate, Monitoring
B-BIL UPS-Bloods-E-PACT,(ESR/Electrolytes Mg, Ca++,Phos, PT/PTT/INR/D-DImer, ABG,Alc levels,5 Cs Cardiac enzy, CPK.CRP,Complement,Culture Blood, TFTs) Imaging, Liquids, Urine, Pregnancy, Stool
T-Treatment
A-ADMIT+ Stop/Compress/Consult/Protect-Activity, Diet, Monitor, Input/Output, Temp/Vitals
C-Counsel
IN A NUTSHELL- >>>D/D-LEBTAC--L---E---GETINPOEM---B---BIL UPS-B-EPACT---T---A-ADMIT/STOP/COMPRESS/CONSLT/PROT---C
USE THIS FRAMEWORK AS A CHECKLIST DURING EXAM AND TAILOR IT TO MEET CASE NEEDS IT WRITE IT ON ROUGH SHEET AS A REMINDER DURING EXAM
PRINT A HARD COPY FOR LAST MINUTE REVISION
THANKS
