Familiarizing Yourself with Primum® CCS Software

Remember playing those language games? Like “give one word for” or for that matter, solving crossword puzzles in your favorite newspaper. A set of cryptic clues, and then you scratch your head, call a few friends, open a dictionary and look for the right word. Sometimes you get it while at others you almost make it. This examination is no different. CCS tests your diagnostic and management skills using exceptionally intelligent and well-structured software. The examination quite closely resembles our day-to-day interaction with patients. Case simulations are set in different management settings. Much like a crossword puzzle, you use the clues, and come up with a diagnosis and manage your patient.

Assume that the patient has consented for all procedures and interventions. If the patient does not want any intervention, the software will let you know. Do not worry about taking consents and looking for a witness.

While dealing with a case simulation, you may find it useful to deal with it in a structured manner. We recommend being wary of these steps in dealing with CCS cases.

• Patient presents to you with his chief complaint.
• Establish hemodynamic stability of the patient by looking at the vitals.
• Perform the required physical examination.
• Order appropriate tests/procedures/interventions on the patient
• Formulate a provisional diagnosis or diagnoses.
• Start treating/ intervening/counseling.
• Schedule the patient for follow up/ relocate the patient appropriately.
• Order final orders and primary diagnosis.

This algorithm is outlined in more details below:

Patient presents to you with his chief complaint.

Patient encounter begins with the patient presenting with chief complaint(s). This is the reason of his visit. At this time, recognize which clinical setting the patient is presenting in. Generally, but not always, clinical setting reflects the acuity of case presentation. If you think it appropriate, you may change the location to a more appropriate location.

Establish the stability of the patient by looking at the vitals

After Initial presentation, the next screen will show the vitals. Vitals of the patient are next in order. For all purposes, at this stage you can establish whether or not the patient is stable. This determines how the patient should be triaged. Also at this point you can think of how much time you will require to treat this patient satisfactorily. However there is no guarantee that your patient will be cured, but the objective of this test is to see whether you have adequately triaged the patient and ordered appropriate investigations and adequately managed the patient.  Remember! For any patient management, ABCs come first. If you think your patient is not hemodynamically stable, you should not waste your time in ordering labs or performing physical examination. First stabilize the patient. Order airway access, intravenous lines and oxygen, depending upon the case. Recognize the opportunity to change the setting if required. If the patient presents to your office with retrosternal crushing chest pain, immediately give him aspirin and nitroglycerine and straight away transfer the patient to the Emergency Room – don’t attempt to treat him in your office!

Perform the required physical examination.

Physical examination should be focused. While a detailed examination is very helpful, the examination should be weighed against the acuity and necessity as warranted by a given presentation. Focus on time management. For instance in acute coronary syndrome, time is muscle! Unnecessary examinations and orders cost you “real and simulated time”. Generally, in a stable patient, presenting in ambulatory setting, you should completely examine the patient. At the same time, it may not be prudent to perform rectal or breast examination in a lady who presents with ongoing seizure activity. You would not want to devote time in eliciting deep tendon reflexes if patient is short of breath or for that matter presents with crushing substernal chest pain. Time economy is a must both in the exam and real life.

Order appropriate tests/procedures/interventions on the patient

Appropriateness and chronology is extremely important. How and what you order in this test reflects how you would practice in real life. In the following pages, the strategies and tips regarding Order Entry are outlined.

Formulate a provisional diagnosis

In most cases the differential diagnosis will become evident well before you start ordering any tests. The introductory statement about the case is an extremely important part. Complete history, physical examination and lab results will almost always allow you to shrink down the differentials to come up with one or two definitive diagnosis.

Start treating/ intervening/counseling

By this time, you have a wealth of information. You already have the history, physical examination, pertinent lab results and probably the diagnosis too. Recognize the opportunity between requesting lab tests and getting the lab results. You can counsel the patient in this time frame. During counseling sessions, such as smoking cessation, alcohol abstinence, safe sex etc. you will be advancing the time and the lab results will start pouring in. Alternatively, you can advance the clock to look for results. However, while you advance the clock by one hour and look at basic metabolic panel and hemogram, the patient is still in your office and you can use this opportunity to educate him. If lab results are likely to determine your management and it is going to take a long time before you get them back, send the patient home and schedule another appointment. You can start treating the patient. If appropriate, admit the patient to the wards.

Schedule the patient for follow up/ relocate the patient appropriately.

By this time, you already have an insight into his problem. You can roughly estimate how long it will be before the patient will improve. Determine your goals here. Do you want to discharge him or admit him? If you want to discharge your patient, how often you would like to see him? What labs you would want before you see him next? Have you incorporated important aspects of management and follow-ups? Have you counseled the patient adequately? Does patient’s age or co morbid condition warrant a vaccination? Does the age or history mandate a colonoscopy?