Step 3 · Day 2 cases

CCS Case Simulations

How a case runs and the orders that move it: stabilize, test, treat, reassess, counsel.

How a case runs & what scores well

Each case is one patient on a simulated clock: order early and in a sensible sequence, advance time to see results, move the patient to the right place, reassess, and finish with prevention and follow-up.

Rules to know

Two clocks in every case → real time is how long you have to work; simulated time is the patient's clock and moves only when you advance it
Case opens → read the introduction, vital signs and initial history; you cannot question the patient, so the history you need is supplied
Choosing physical exam components → pick only what the problem calls for; the software tells you how much simulated time the exam will use
Unstable patient at the start → enter stabilizing orders first or alongside a brief focused exam; a long exam spends the patient's time
Writing orders → type free text (an abbreviation like CBC or the full name both work), choose the exact match from the list, confirm each
Look-alike entries in the order list → read carefully; a cell count, for example, must name the fluid, or the wrong test is placed
Tests or checks that should repeat → set the repeat frequency when confirming the order instead of reentering it by hand
Ordering a drug → name the specific drug, generic or brand, and pick the route; the dose is set for you, and a drug class is not an order
Orders entered → nothing is carried out until simulated time moves; the order sheet shows when each result will report
Waiting on a key result → advance to the next available result, read it, act, then advance again
Sick or changing patient → move the clock in short steps and recheck vital signs and a focused exam each time
Stable outpatient ready to leave → send home with a return visit on a set day and time, or ask to be called as needed
Message that the patient is worse while time passes → stop, bring the patient in or move up a level of care, re-examine, add orders
Different care setting needed → change location (office, home, emergency department, ward or ICU) and review the vital signs on arrival
Medications already on the chart at the start → review them; stop any that caused the problem or are now harmful, keep the rest
Specialist input needed → order the consult with the specialty and a short reason; you still own every other order
Case-end warning → you can still add or cancel orders but cannot examine, move the patient or advance time; pending results will not return
Final minutes of a case → enter what is still owed: discharge drugs, counseling, vaccines, follow-up and any consult
Real time differs by case and may run short → put critical orders in first; you may not need the full time allowed
What is known to matter for scoring → needed actions done promptly and in a sensible order, in the right setting; the exact formula is not published
Risky or invasive tests without a clear reason → likely to count against you even when the patient does well; order what the findings justify
Critically ill patient awaiting confirmation → treat first (oxygen, glucose, antibiotics, epinephrine, fluids), confirm after; the simulated patient worsens with delay
Returning patient → interval history and a focused repeat exam before changing treatment
Office complaint handled → add the screening, vaccines and counseling due for age and sex before the case ends
Patient improving on treatment → step down: oral drugs, lower level of care, stop monitors and lines no longer needed, then discharge with follow-up
Diagnosis still uncertain → start orders that are safe and useful across the likely causes; narrow therapy as results return

Traps that cost points

Entering orders and then waiting without moving the clock→ Orders are carried out only as simulated time advances. Advance to the next available result, read it, and respond.
Jumping ahead several days while the patient is still unstable→ Large time jumps let a sick patient deteriorate unseen. Advance in short steps and recheck vitals until the patient is stable.
A full head-to-toe exam on a crashing emergency patient→ Each exam component uses simulated time. Start monitoring, oxygen, access and urgent treatment, then examine the systems that matter.
Typing a drug class such as antibiotics or beta blocker→ Orders need a named drug (ceftriaxone, metoprolol) and a route; the software chooses the dose.
Ordering every test you can think of, just to be safe→ Unneeded tests waste time and invasive ones can harm. Order what the presentation supports and add more as results guide you.
Saving counseling and follow-up for after the end warning→ Time is short then and easy to lose; enter preventive and discharge orders as soon as the patient is stable.
Leaving a recovered patient in the ICU on IV drugs→ Step care down as the patient recovers: switch to oral drugs, transfer to the ward or home, and arrange follow-up.
Ordering a consult and then stopping your own management→ Consultants add expertise, but you remain the treating physician; keep monitoring, treating and reassessing.
Ignoring the medication list given at the start of the case→ Some cases begin on a drug that causes or worsens the problem; review the chart early and stop it.

Stabilize first: opening orders & the right unit

In the Brain

In an unstable patient, monitoring, oxygen, access and bedside tests go in during the first simulated minutes; treatment, consults and the right bed follow.

Rules to know

Emergency case with abnormal vital signs → cardiac monitor, pulse oximetry, IV access and targeted labs, entered while a focused exam runs
Low oxygen saturation → supplemental oxygen to about 92–96%; 88–92% if the patient chronically retains CO2
Hypotension with poor perfusion → two large-bore IVs, crystalloid bolus, recheck BP, mental status and urine output; vasopressor if fluids fail
Confusion, seizure or unresponsiveness → bedside glucose immediately; dextrose if low, with thiamine if malnourished or a heavy drinker
Woman who could be pregnant, before imaging or risky drugs → urine or serum hCG early; also with abdominal pain, bleeding or syncope
Chest pain, dyspnea, syncope, palpitations, overdose or potassium disorder → 12-lead ECG within minutes
Cannot protect the airway, GCS 8 or less, or failing ventilation → intubation, mechanical ventilation and ICU admission
Pinpoint pupils and slow shallow breathing → naloxone (IV, IM or intranasal) with bag-mask support; watch for recurrence as it wears off
Hemorrhage with shock → type and crossmatch, red cells with plasma and platelets in a balanced ratio, and stop the source (surgery, endoscopy, interventional radiology)
Life-threatening bleed on an anticoagulant → warfarin: 4-factor PCC plus IV vitamin K; factor Xa inhibitor: andexanet or 4-factor PCC; dabigatran: idarucizumab
Hyperkalemia with ECG changes → IV calcium first, then insulin with dextrose and albuterol, then remove potassium (binder, diuretic or dialysis)
Hypertensive emergency with organ damage → ICU and IV labetalol, nicardipine or clevidipine; lower mean pressure no more than 25% in the first hour
Trauma → primary survey in order: airway with spine protection, breathing, circulation (bleeding control, IV, bedside ultrasound), disability, exposure; imaging after
Unstable patient in the office → send to the emergency department now; do not continue an office workup
Shock, intubation, vasopressors, or frequent titration and checks → admit to the ICU
Stable but needs IV treatment, monitoring or tests → ward bed, with telemetry if arrhythmia or ischemia is possible
Improved after emergency care, low risk, reliable follow-up → home with return precautions and an office visit
Needs a procedure you cannot do (endoscopy, surgery, catheterization, delivery) → order the consult early and keep treating meanwhile
Shock or critical illness → urinary catheter to track urine output (goal at least 0.5 mL/kg/h); avoid catheters otherwise
Severe pain in the emergency department → titrated IV opioid; pain relief does not hide surgical findings
Likely to need surgery or endoscopy → NPO with IV fluids and an antiemetic; nasogastric tube for obstruction or persistent vomiting
Fever with hypotension or suspected serious infection → blood cultures, then broad antibiotics within the hour; imaging does not come first
Undifferentiated sick adult → CBC, metabolic panel and lactate; add troponin, blood gas, type and screen or cultures as the picture suggests

Traps that cost points

Sending an unstable patient to CT before resuscitation→ Patients deteriorate in the scanner. Secure airway, access and fluids or blood first, and image once stable or use bedside ultrasound.
Working up confusion without a fingerstick glucose→ Hypoglycemia is quick to find and fix and mimics stroke, seizure and intoxication; check it in the first minutes.
Skipping the pregnancy test before CT or a teratogenic drug→ Pregnancy changes imaging, drug choice and the differential, including ectopic pregnancy; get hCG early in anyone who could be pregnant.
Admitting a patient on a norepinephrine drip to the ward→ Vasopressors, intubation or frequent titration need ICU-level nursing and monitoring.
Normalizing blood pressure quickly in a hypertensive emergency→ Rapid falls cause brain, heart and kidney ischemia; lower mean pressure by no more than about 25% in the first hour, except in aortic dissection.
Giving only vitamin K for a brain bleed on warfarin→ Vitamin K takes hours to work; 4-factor PCC reverses within minutes, and vitamin K keeps the INR down.
Waiting for the consultant to arrive before treating→ Start fluids, blood, antibiotics or other urgent therapy now; the consultant adds the procedure, not the first hour of care.
Placing a urinary catheter in every emergency patient→ Catheters cause infection and delirium; use them for shock, retention, strict output measurement or specific procedures.
Withholding pain medicine until the surgeon examines→ Analgesia does not reduce diagnostic accuracy in acute abdominal pain; treat pain promptly.

Chest pain, breathing & shock cases

In the Brain

Get the ECG and the life-saving drug in early, put the patient where they can be watched, and confirm response with repeat vitals and the key test before stepping down.

Rules to know

Possible cardiac chest pain → monitor, IV, ECG within 10 minutes, high-sensitivity troponin repeated at 1–3 hours, chewed aspirin, chest x-ray; oxygen only below 90%
ST elevation in contiguous leads → aspirin, P2Y12 inhibitor, heparin, cardiology consult for primary PCI; fibrinolysis if PCI is over 120 minutes away
NSTEMI → aspirin, heparin or enoxaparin, high-intensity statin, beta blocker if no heart failure or shock, telemetry or CCU; early angiography if high risk
Nitroglycerin for ischemic pain → not with SBP under 90, right ventricular infarct, or a recent PDE-5 inhibitor
Tearing pain to the back with unequal arm pulses or pressures → aortic dissection; CT angiography (TEE if unstable), IV esmolol then a vasodilator, surgery for type A
Suspected PE in a stable patient → low pretest probability: PERC or D-dimer; otherwise CT pulmonary angiography; start heparin meanwhile if likely and bleeding risk low
PE with persistent hypotension → systemic thrombolysis unless contraindicated, ICU; catheter or surgical clot removal if lysis is not possible
Stable PE with a low-risk score and good home support → apixaban or rivaroxaban and early discharge
Asthma attack → nebulized albuterol with ipratropium, systemic steroid within the first hour, oxygen, peak flow; IV magnesium if severe
Asthma attack with normal or rising PCO2, drowsiness or a quiet chest → tiring toward respiratory failure; ICU and prepare to intubate
Asthma attack resolved → short oral steroid course, start or step up an ICS-formoterol regimen, check inhaler technique, written action plan, visit within 1–2 weeks
COPD exacerbation → bronchodilators, prednisone 40 mg for 5 days, antibiotic if sputum is purulent, oxygen to 88–92%, blood gas
COPD exacerbation with pH under 7.35 and PCO2 over 45 → noninvasive positive-pressure ventilation; intubate if it fails or the airway is unprotected
Acute pulmonary edema → sit up, oxygen or noninvasive ventilation, IV furosemide, nitroglycerin if hypertensive; BNP, troponin, echo; daily weights and electrolytes
Tachycardia with hypotension, ischemic pain, altered mental status or shock → synchronized cardioversion
Pulseless VT or VF → CPR and defibrillation, epinephrine every 3–5 minutes, amiodarone for a rhythm that persists
Stable regular narrow-complex tachycardia → vagal maneuvers, then rapid IV adenosine
Atrial fibrillation with rapid rate in a stable patient → diltiazem or metoprolol (beta blocker if EF reduced), TSH, echo; anticoagulate by CHA2DS2-VASc
Symptomatic bradycardia → atropine, then transcutaneous pacing or an epinephrine or dopamine infusion; check potassium, drug levels and ischemia
Anaphylaxis → IM epinephrine 0.3–0.5 mg in the outer thigh, repeat every 5–15 minutes; fluids and oxygen; antihistamine and steroid only as add-ons
Anaphylaxis settled → observe several hours, then discharge with an epinephrine autoinjector, trigger avoidance and allergy referral
Sepsis with hypotension or lactate 4 or more → cultures, antibiotics within 1 hour, 30 mL/kg crystalloid, norepinephrine for MAP under 65, ICU, repeat lactate
Sudden dyspnea, absent breath sounds, hypotension, tracheal shift → tension pneumothorax; needle decompression now, chest tube after, no x-ray first
Low BP, raised jugular venous pressure and faint heart tones → tamponade; bedside echo, IV fluids, pericardiocentesis
Pneumonia → severity score for site of care; outpatient amoxicillin or doxycycline; ward ceftriaxone plus azithromycin; cultures when severe
Syncope → ECG, orthostatic vitals, glucose, hCG; admit to telemetry if exertional, abnormal ECG, structural heart disease or family sudden death
Discharge after ACS → aspirin, P2Y12 inhibitor for 12 months, high-intensity statin, beta blocker, ACE inhibitor if EF 40% or less, cardiac rehab, smoking cessation
After any chest or breathing emergency → repeat vitals, exam and the key test (troponin, blood gas, lactate) to confirm response before stepping down

Traps that cost points

Giving oxygen to every chest pain patient with a saturation of 97%→ Oxygen helps only when saturation is under 90%; routine oxygen in ACS with normal saturation shows no benefit.
Waiting for troponin before aspirin in suspected ACS→ Aspirin lowers mortality and is safe in nearly everyone; give it chewed as soon as ACS is suspected.
Giving heparin for chest pain before excluding aortic dissection→ Pain to the back, pulse differences or a wide mediastinum call for CT angiography first; anticoagulation in dissection can be fatal.
Ordering CT angiography for low-probability PE→ Apply PERC or a D-dimer first; imaging low-risk patients exposes them to contrast and radiation with few true positives.
Feeling reassured by a normal PCO2 in a severe asthma attack→ During an attack the PCO2 should be low; a normal or rising value means fatigue and impending failure.
Using high-flow oxygen to normal saturation in a CO2-retaining COPD patient→ Excess oxygen worsens hypercapnia; titrate to 88–92% and check a blood gas.
Giving diltiazem to atrial fibrillation with severely reduced EF→ Nondihydropyridine calcium blockers depress contractility; use a beta blocker if compensated, or amiodarone or digoxin if decompensated or hypotensive.
Leading with diphenhydramine and steroids for anaphylaxis→ Only epinephrine reverses airway swelling and shock; give it IM first, and repeat it if needed.
Ordering a chest x-ray before decompressing a tension pneumothorax→ It is a clinical diagnosis in a crashing patient; decompress immediately, then place a chest tube.

Abdominal pain, GI bleeding & ectopic pregnancy cases

In the Brain

Resuscitate, keep the patient NPO, choose the imaging that fits the patient, and call the surgeon, endoscopist or gynecologist early while you keep managing.

Rules to know

Upper GI bleed → two large-bore IVs, crystalloid, CBC, coagulation studies, type and crossmatch, IV PPI, NPO, GI consult for endoscopy within 24 hours
Transfusion trigger in GI bleeding → hemoglobin under 7 g/dL, under 8 with heart disease, or earlier with ongoing brisk bleeding and instability
GI bleeding in known or suspected cirrhosis → add octreotide and ceftriaxone, band ligation within 12 hours, ICU; avoid overtransfusion
Brisk hematochezia with shock → consider an upper source and do EGD first; CT angiography if bleeding persists; colonoscopy after prep once stable
Epigastric pain to the back with high lipase → pancreatitis; moderate lactated Ringer's, analgesia, ultrasound for gallstones, triglycerides and calcium
Pancreatitis management → oral feeding once tolerated, no prophylactic antibiotics; CT only if the diagnosis is unclear or no improvement after 48–72 hours
Mild gallstone pancreatitis → cholecystectomy during the same admission; ERCP only for cholangitis or persistent obstruction
RUQ pain, fever, Murphy sign → ultrasound, NPO, IV fluids, analgesia, IV antibiotics, surgery consult for cholecystectomy within about 72 hours; HIDA if ultrasound is equivocal
Fever, jaundice and RUQ pain, possibly with hypotension or confusion → cholangitis; blood cultures, broad antibiotics, fluids, GI consult for ERCP, urgent if septic
Suspected appendicitis in an adult → CBC, hCG, urinalysis, CT abdomen-pelvis with contrast, NPO, IV fluids, analgesia, antibiotics, surgery consult
Suspected appendicitis in a child or a pregnant patient → ultrasound first; MRI if the pregnancy ultrasound is unclear
Vomiting, distension and no stool or gas after prior surgery → small bowel obstruction; NPO, nasogastric suction, IV fluids, electrolytes, CT, surgery consult
Obstruction with fever, peritonitis, rising lactate or leukocytosis → strangulation; emergency surgery
Sudden severe pain with a rigid abdomen or free air → perforation; NPO, fluids, broad antibiotics, emergency surgery consult; no endoscopy
Pain out of proportion to the exam in atrial fibrillation → mesenteric ischemia; CT angiography, heparin, fluids, vascular surgery
Older adult with abdominal or back pain, hypotension, pulsatile mass → ruptured aortic aneurysm; vascular surgery now, permissive hypotension, blood ready
Positive pregnancy test with pain or bleeding → transvaginal ultrasound, quantitative hCG, CBC, blood type and Rh
Ruptured ectopic (hypotension, peritoneal signs, free fluid) → fluids, blood and an emergency gynecology consult for surgery
Stable unruptured ectopic, low hCG, no cardiac activity, reliable follow-up → methotrexate with hCG on days 4 and 7; anti-D immune globulin if Rh-negative
Sudden one-sided pelvic pain with an adnexal mass → ovarian torsion; Doppler ultrasound and gynecology for laparoscopy
Acute scrotal pain, high-riding testis, absent cremasteric reflex → testicular torsion; urology for immediate surgery, no imaging delay when classic
Left lower quadrant pain with fever → CT if first episode or complications suspected; stable uncomplicated cases go home, some without antibiotics; abscess over 3 cm → drain
Older adult with abdominal pain → add ECG, lipase and lactate; MI, aneurysm and ischemia can masquerade as benign pain

Traps that cost points

Transfusing a variceal bleeder to a hemoglobin of 10→ Overtransfusion raises portal pressure and rebleeding; aim for about 7–8 g/dL unless the patient is actively unstable.
Running liters of fluid per hour in pancreatitis→ Very aggressive fluid adds overload without better outcomes; use moderate goal-directed lactated Ringer's and reassess often.
Starting prophylactic antibiotics in sterile pancreatitis→ They do not prevent infected necrosis; reserve antibiotics for proven or strongly suspected infection or cholangitis.
Ordering CT first for suspected appendicitis in a child or pregnancy→ Ultrasound avoids radiation and answers most cases; add MRI in pregnancy if ultrasound is unclear.
Requesting endoscopy for suspected perforation→ Insufflation worsens a perforation; get CT or upright film and an emergency surgery consult.
Giving methotrexate to a hypotensive patient with an ectopic pregnancy→ Instability means rupture; resuscitate and send to surgery. Methotrexate is only for stable, unruptured cases with reliable follow-up.
Forgetting anti-D immune globulin after an ectopic pregnancy in an Rh-negative patient→ Check blood type in every early pregnancy bleed and give anti-D when Rh-negative.
Waiting for scrotal ultrasound in classic testicular torsion→ Testicular salvage falls quickly after about 6 hours; send for surgical exploration without delay.

Neurologic, toxic, psychiatric & pediatric emergency cases

In the Brain

Check glucose, protect the airway, give time-critical treatment before confirmatory tests, keep patients safe, and treat children by age-specific rules.

Rules to know

Altered mental status → glucose, oxygenation and vitals; then metabolic panel, CBC, urinalysis, toxicology, ethanol, acetaminophen and salicylate levels, ECG; head CT if focal, trauma or anticoagulated
Sudden focal deficit → fingerstick glucose and immediate noncontrast head CT with CT angiography; record the last-known-well time
Disabling ischemic stroke within 4.5 hours, no contraindication → IV alteplase or tenecteplase once BP is under 185/110
Large-vessel occlusion within 24 hours with salvageable tissue → mechanical thrombectomy, transfer to a stroke center
Ischemic stroke not given lytic therapy → allow BP up to 220/120, aspirin within 24–48 hours, swallow screen, DVT prophylaxis, statin, telemetry, echo
Minor stroke or high-risk TIA → aspirin plus clopidogrel for 21 days, then one antiplatelet; urgent vascular imaging
Intracerebral hemorrhage → reverse anticoagulation, aim for systolic BP about 140 (not under 130), neurosurgery consult, ICU
Fever, headache, stiff neck → blood cultures, then dexamethasone with ceftriaxone and vancomycin at once (ampicillin if over 50 or immunocompromised); then LP
CT before LP in suspected meningitis → only with focal deficit, papilledema, new seizure, immunocompromise or reduced consciousness; antibiotics never wait for it
Seizure lasting over 5 minutes → IV lorazepam or IM midazolam, then fosphenytoin, levetiracetam or valproate; glucose check; ICU if it continues
First unprovoked seizure, back to baseline → glucose, electrolytes, hCG, toxicology, brain imaging, EEG; counsel on driving per state law
Acetaminophen overdose → level at 4 hours on the nomogram; N-acetylcysteine if above the line, if timing is unknown with a detectable level, or if enzymes are rising
Unknown ingestion → glucose, ECG, acetaminophen, salicylate and ethanol levels, poison control; charcoal only within about 1 hour and with a protected airway
Wide QRS after an overdose (tricyclic) → IV sodium bicarbonate
Salicylate poisoning → IV bicarbonate to alkalinize urine, keep potassium normal; dialysis for altered mental status, kidney failure or very high levels
Overdose or suicidal statement → after medical stabilization, one-to-one observation, remove means, psychiatry consult; involuntary hold if danger is imminent
Alcohol withdrawal → symptom-triggered benzodiazepine by a withdrawal scale, thiamine, electrolytes; ICU for delirium tremens
Hospital delirium → look for the cause (infection, drugs, retention, pain, sodium); reorient, protect sleep, mobilize; antipsychotic only for dangerous agitation
Severely agitated patient → verbal de-escalation, then IM haloperidol or olanzapine with or without lorazepam; restraint only as a last resort, checked often
Back pain with leg weakness in a cancer patient → cord compression; IV dexamethasone, emergency whole-spine MRI, oncology and neurosurgery
Febrile infant 28 days old or younger → blood and urine cultures, lumbar puncture, admit for IV ampicillin plus gentamicin or ceftazidime; acyclovir if HSV risk
Child with mild or moderate dehydration → oral rehydration solution in small frequent sips, ondansetron if vomiting; IV only if oral fails
Child with severe dehydration (lethargy, poor perfusion) → 20 mL/kg isotonic saline boluses, glucose check, admission
Story not matching injury, delayed care, bruised non-cruising infant → suspect abuse; skeletal survey under age 2, head imaging, eye exam, labs
Suspected child abuse → report to child protective services (certainty not required), admit if home is unsafe, tell the family a report is being made
Simple febrile seizure in a well child 6 months to 5 years → find the fever source; no routine labs, EEG or imaging; reassure and counsel
Infant with bronchiolitis → suction, oxygen if saturation under 90%, hydration; no routine albuterol, steroids, antibiotics or chest x-ray
Barking cough with stridor → single dose of dexamethasone; nebulized epinephrine for stridor at rest, then observe 2–4 hours
Headache in several household members in winter → carbon monoxide; 100% oxygen by nonrebreather, carboxyhemoglobin level, hyperbaric oxygen if severe

Traps that cost points

Holding antibiotics for suspected meningitis until CT and LP are done→ Draw blood cultures and give dexamethasone plus antibiotics immediately; imaging and LP follow without delaying treatment.
Lowering blood pressure to normal in ischemic stroke without lytic therapy→ Brain tissue at the margin depends on pressure; allow up to 220/120 unless another condition demands lowering.
Giving a lytic before checking glucose and noncontrast CT→ Hypoglycemia mimics stroke and hemorrhage must be excluded; glucose and CT come first.
Giving activated charcoal to a drowsy patient without airway protection→ Aspiration of charcoal causes severe pneumonitis; use it only early, for an adsorbed toxin, with a protected airway.
Discharging a medically cleared overdose patient without psychiatric assessment→ An intentional overdose is a suicide attempt; keep the patient observed and safe until psychiatry evaluates risk.
Using lorazepam for delirium in an older inpatient→ Benzodiazepines worsen delirium except in alcohol or sedative withdrawal; treat the cause and use nondrug measures.
LP, CT and EEG for a simple febrile seizure in a well toddler→ Simple febrile seizures need only a search for the fever source; reserve LP for meningeal signs or an ill-appearing child.
Confronting parents or waiting for proof before reporting abuse→ Reasonable suspicion triggers mandatory reporting; protect the child, report, and explain calmly to the family.
Starting IV fluids for mild dehydration in a child who can drink→ Oral rehydration with small frequent volumes works as well and avoids needles; add ondansetron for vomiting.
Treating bronchiolitis with albuterol and steroids→ Neither changes the course; give supportive care with suction, hydration and oxygen when saturation is under 90%.

Office & continuing-care cases

In the Brain

Treat the complaint, then add the prevention due for age and sex, and set the right recheck interval for every drug and chronic disease.

Rules to know

Office case after the complaint is handled → add the screening, vaccines and counseling due for age, sex and risk
Any tobacco use → advise quitting, offer varenicline or combination nicotine replacement with counseling, follow up on the quit attempt
Counseling the patient needs → enter it as specific orders (diet, exercise, weight, safe sex, seat belts, helmets, firearm storage, sun protection, falls)
Adults 18 and over → blood pressure screening yearly from 40 or with risk factors, every 3–5 years if younger with normal readings
Adults 35–70 with overweight or obesity → screen for prediabetes and diabetes, repeating about every 3 years if normal
Adults 40–75 with a risk factor → lipids and 10-year risk estimate; statin when risk is 10% or more
Average-risk adults 45–75 → colorectal screening by colonoscopy every 10 years, yearly FIT, stool DNA-FIT every 1–3 years, or CT colonography every 5 years
Women 40–74 → screening mammogram every 2 years
Cervical screening → cytology every 3 years from 21 to 29; at 30–65, HPV testing every 5 years, cotesting every 5, or cytology every 3
Ages 50–80, 20 pack-years, smoking now or quit within 15 years → yearly low-dose chest CT
Men 65–75 who ever smoked → one-time abdominal ultrasound for aortic aneurysm
Women 65 and older, or younger postmenopausal women at risk → bone density by DXA
Infection screening for adults → HIV at least once (15–65), hepatitis C once (18–79), hepatitis B at least once
Sexually active women 24 and younger, or older with risk → yearly chlamydia and gonorrhea testing
Adult mental health and alcohol screening → depression for all, anxiety under 65, unhealthy alcohol use; act on positive screens
Adult vaccines → influenza yearly, Td or Tdap every 10 years, recombinant zoster from 50, pneumococcal from 50, hepatitis B and HPV catch-up by age
Pregnant patient in the office → Tdap each pregnancy at 27–36 weeks, influenza in season, RSV vaccine at 32–36 weeks in season unless the infant gets antibody
Live vaccine due (MMR, varicella) in someone pregnant or severely immunosuppressed → defer it
New ACE inhibitor, ARB or diuretic → potassium and creatinine in 1–2 weeks; see monthly until BP is at goal
Diabetes → A1c every 3 months if above goal or therapy changed, every 6 months if stable; yearly urine albumin-to-creatinine, eGFR, eye and foot exams
Statin started → lipid panel in 4–12 weeks to check response and adherence; CK and liver tests only for symptoms
Levothyroxine started or dose changed → TSH in 6–8 weeks
Lithium → level about 5 days after any dose change, then every 3–6 months; creatinine, TSH and calcium periodically
Amiodarone → thyroid and liver tests at baseline and every 6 months, baseline chest x-ray and lung function, eye exam if vision changes
Methotrexate → CBC, liver tests and creatinine every few weeks at the start, then every 8–12 weeks once stable
Adolescent visit → time alone with the teen, ask about home, school, activities, drugs, sex, mood and safety; depression screening from 12
Well-child visit → growth, development, hemoglobin near 12 months, lead risk, vision and hearing, rear-facing car seat as long as it fits, water and firearm safety
Older adult visit → ask about falls and test gait, exercise for fall prevention, hearing, vision, cognition if concerns, advance care planning, deprescribing
Abnormal result after the visit → act on it: contact the patient, treat or order the next test, and set a recheck date
Choosing a return interval → usually 2–4 weeks after starting or changing treatment, every 3–6 months for stable chronic disease, sooner if worse

Traps that cost points

Ending an office case once the presenting problem is treated→ Office cases reward complete care; add due screening, vaccines and counseling before time runs out.
Ordering screening tests with no proven benefit, such as CA-125 or routine ECGs in low-risk adults→ Order only screening supported for the patient's age and risk; false positives lead to invasive follow-up.
Rechecking A1c every month after a medication change→ A1c reflects about 3 months of glucose; recheck at 3 months and use glucose readings in between.
Checking TSH one week after a levothyroxine change→ TSH takes about 6 weeks to settle; recheck at 6–8 weeks.
Ordering routine CK and liver tests at every statin visit→ Check them for symptoms or a baseline; routine monitoring finds noise, not harm.
Doing yearly Pap smears for a 25-year-old with normal results→ Cytology every 3 years is enough at 21–29; over-screening finds transient changes that would clear.
Giving MMR or varicella vaccine to a pregnant patient→ Live vaccines are deferred until after delivery; check immunity and vaccinate postpartum.
Interviewing a 15-year-old only with a parent in the room→ Offer confidential time alone; teens disclose substance use, sex and mood problems more honestly without a parent present.

Inpatient, postoperative, ICU & discharge cases

In the Brain

Prevent what hospitals cause, time post-op fever correctly, manage the ventilator safely, and send patients home with reconciled drugs, warnings and a booked follow-up.

Rules to know

Fever within 48 hours of surgery → usually inflammatory; check the wound for necrotizing infection, encourage incentive spirometry and walking, avoid reflex cultures
Fever on postoperative days 3–7 → examine wound, lungs, lines and calves; CBC, urinalysis and culture, blood cultures, chest x-ray
Fever and pain or ileus 5–7 days after bowel surgery → anastomotic leak or abscess; contrast CT, antibiotics, drainage or reoperation
Rising end-tidal CO2, rigidity and fever under anesthesia → malignant hyperthermia; stop the trigger, IV dantrolene, cooling, ICU
Every admission → assess VTE risk; at-risk medical patients get LMWH or subcutaneous heparin; high bleeding risk → intermittent pneumatic compression
Hip or knee replacement → anticoagulant prophylaxis (LMWH, DOAC or aspirin by protocol) continued for weeks after discharge
Platelets fall by half 5–10 days into heparin → HIT; stop all heparin including flushes, start argatroban or another non-heparin anticoagulant, send PF4 antibody
Hip fracture in an older adult → surgery within 24–48 hours, nerve block, VTE prophylaxis, delirium prevention, early mobilization, osteoporosis treatment
Ventilated patient → head of bed 30–45°, daily sedation pause with spontaneous breathing trial, VTE prophylaxis, mouth care
ARDS → tidal volume 6 mL/kg of predicted body weight, plateau pressure 30 or less, PEEP, prone positioning if PaO2/FiO2 under 150
Sudden desaturation on the ventilator → bag by hand and check for tube displacement, obstruction, pneumothorax or equipment failure
Stress ulcer prophylaxis → only for ventilation over 48 hours or coagulopathy; stop it at transfer or discharge
Low urine output after surgery → bladder scan or catheter first, then volume status; fluid bolus if dry, stop nephrotoxins
Postoperative ileus → walking, fewer opioids, correct potassium and magnesium; nasogastric tube only for vomiting or distension
Hospital hyperglycemia → basal plus mealtime insulin with correction doses, target 140–180 mg/dL; sliding scale alone is inadequate
Elective surgery on warfarin → stop 5 days before; bridge only for the highest clot risk, such as a mechanical mitral valve
Elective surgery on a DOAC → stop 1–2 days before, longer with poor kidney function or high-bleed procedures; no bridging
SGLT2 inhibitor before surgery → hold about 3 days to avoid euglycemic ketoacidosis
Wound edges separating with salmon-colored drainage → dehiscence; if bowel is visible, cover with sterile saline-moist gauze and return to the operating room
Fever in a patient with a central line → cultures from line and periphery, vancomycin; remove the line for S aureus, Candida, tunnel infection or septic shock
Fever, back pain or hypotension during transfusion → stop it, keep the IV open with saline, recheck patient identity, send a blood bank workup
Hospital discharge → medication reconciliation, plain-language warning signs, primary care visit within 7–14 days, and a named owner for pending results
Heart failure discharge → daily weights, guideline therapy started or continued (ARNI or ACE inhibitor or ARB, beta blocker, MRA, SGLT2 inhibitor), visit within 7 days
Deconditioned older patient near discharge → physical and occupational therapy assessment; home health, rehabilitation or skilled nursing as needed
Smoker in hospital → start cessation medication during the stay and continue after discharge; give due vaccines before leaving
Postoperative urinary retention → bladder scan and straight catheterization; review anticholinergic drugs and opioids
Bedbound inpatient → reposition at least every 2 hours, pressure-redistributing mattress, moisture control and nutrition to prevent pressure injury
Indwelling urinary catheter → review daily and remove as soon as it is no longer needed

Traps that cost points

Ordering a full culture workup for a fever on postoperative day 1→ Early fever is usually inflammatory; examine the wound and lungs and treat cultures as targeted tests, not a reflex.
Switching straight to warfarin when HIT is diagnosed→ Warfarin early in HIT can cause limb gangrene; use a non-heparin anticoagulant and start warfarin only after platelets recover.
Bridging every warfarin patient with LMWH before surgery→ Bridging adds bleeding without fewer clots in most atrial fibrillation patients; reserve it for the highest-risk valves or recent clots.
Giving stress ulcer prophylaxis to every inpatient→ Acid suppression raises C difficile and pneumonia risk; use it only for prolonged ventilation or coagulopathy.
Using sliding-scale insulin alone for a hospitalized diabetic→ Reactive dosing chases highs and lows; scheduled basal and mealtime insulin with correction gives steadier control.
Giving furosemide for postoperative oliguria before checking the bladder→ Retention and hypovolemia are the common causes; scan or catheterize first, then assess volume.
Ventilating ARDS with 10 mL/kg tidal volumes to normalize CO2→ Large breaths injure the lung; low tidal volume with permissive hypercapnia lowers mortality.
Discharging without reconciling home and hospital medications→ Duplications and omissions at discharge are a leading cause of readmission; reconcile every drug and explain changes.
Leaving a urinary catheter in for convenience→ Each catheter day adds infection risk; remove it once strict output or retention no longer requires it.