I) STABILIZE ABCD/DDX II) PE: III) DX INVESTIGATIONS
FOCUSED VS
-Pulse Oximetry -IV access -Oxygen -Cardiac Routine: CBC, BMP, UA Advanced Specific: EKG, card enzymes
GENERAL
monitor, BP monitor
Images: XR, US, CT, MRI, Echo
Emergent orders Blood : BMP, CBC, BCx, ABG, TSH, LFT, ESR,ABG,
-Aspirin -Nitroglycerin (depends on BP) BASIC INFO PT/INR,PTT,CCP, RF, ANA, anti ds DNA, Iron, TIBC, Fe,
-Manage Pain (Morphine), Ketorolac Gender, Age Transferrin, Haptoglobin
-BP (Metoprolol) -NSS -EKG Social: Sex Urine: UA, UTox, ketones
-FSG, LOC ETOH Smoke
-Naloxone, Dextrose, Thiamine Other: EKG, PEFR, Peak flow, Lumbar puncture, FOBT, blood
Drugs
*CHEST DISCOMFORT OR SOB: TROPONIN, culture, CSF, synovial fluids, sputum, arthrocentesis
D-DIMER, BNP Pregnancy urine HCG childbearing age
IV) AFTER DX: Triage-Location: V) SYMPTOM MANAGEMENT/ TREATMENT
ER, ICU, Ward, Home
-IV access -Fluids -DIET: NPO, Ad Lib (frequent small feedings)
Consults
-ACTIVITY: Bed rest HOB elevated VITALS: Q4, Q8 DVT prophylaxis :
Need surgery? Consult surgery team and Prepare Consent
Abx: cefazolin, Labs: Type and cross, NPO, IV access, LMWH, Pneumatic compression Tubes: NG, Foley Urine output
NSS, PT, PTT, INR, CXR, CBC/BMP/UA, IV CEFAZOLIN, Meds: Pain: Morphine, NSAIDS, acetaminophen, PPI
Meds: IV MORPHINE, IV PHENERGAN, ABD US/XRAY, Nausea: Zofran, Phenergan, Diarrhea: Loperamide, Cramping: Dyciclomine
STOP WARFARIN/HEPARIN, SURGERY ORDER Abx, Steroids Monitoring labs: H&H, CRP, BMP, ESR, CBC, O2, BP,
(APPENDECTOMY, LAPAROTOMY, ETC). VITALS, PE & Interval Hx
VII) COUNSELING/CLOSURE VI) REASSES: PE focused vs general, Interval Hx
Educate pt. and family Final orders: Now or Later, dates
(Type) Counsel: Relaxation, age related, Smoke, illicit drugs, Labs to monitor (ESR)
exercise, limit ETOH, safe driving (seat belt), safe sex,
sunscreen, exercise, diet, med compliance, med side effects,
SCREENING : VIII) FINAL DIAGNOSIS
CY, Pap ( 23), Teen (HPV), Mammo, Vaccines: Flu, DEXA, New meds
Pneumo, zoster, PPD, Hep C, Advance directive (pt. over 60 y)
(Type Vaccine, list will show up)
AVAILABLE MEDS
MONOCLONAL AB: INFLIXIMAB
HIV TX: **EFAVIRENZ, TENOFOVIR, EMTRICITABINE.. Also available ZIDOVUDINE, LAMIVUDINE,
BRAND NAMES:
Bactrim: trimethropin-sulfamethoxazol, Augmentin: amox-clavulanic acis, Librium: chlordiazepoxide, Lipitor: Atorvastatin
Bentyl: dyciclomine
LAB FREQUENCY
DKA: fingerstick every 1 h, BMP every 4 h
Sepsis: cbc every 24 h
Acute coronary syndrome: Troponin/EKG every 4 h
CONSULTATION:
Colon cancer: GI, Oncology, General surgery, cancer diagnosis
Fall: neurology, Cardiology, Orthopedic surgery (if fracture)
1. Basic information
Write down the age, gender, medical history, social history, allergies - note down for counseling and for formulating
Ddx.
Note location - usually if ED then usually they are unstable.
2. Emergent or non-emergent?
After reading through the HPI, decide emergency vs non-emergency - if low BP, high RR, then consider emergent.
Routine patient in office - Do Physical Examination after case history ends.
Acute distress patient in ER- Do emergency orders after case history ends.
Acute distress patient in Office- morphine/vitals check / Gen appearance + CVS+RS exam → shift to ER.
If emergent, you need to do emergency orders before doing the physical exam. (e.g., chest pain, sob, confusion,
hypotension).
Emergent (Life-threatening situation):
Basic Orders: remember to set frequency
MAVOC + Fluids (only when needed)
M- (TYPE “MOR”) Morphine IV (can be given in all pain patients EXCEPT those in HYPOTENSION as morphine leads to
peripheral vasodilatation- give Fentanyl/ Ketorolac in that case).
A- (TYPE “ACC”) Select- “Access IV” (+ NSS) and “Accucheck Glucose” +/- “Antibiotics”
V- (TYPE “VIT”) Select Vitals every 1 hour
O- (TYPE “OXY”)- Select “PULSE OXIMETER q1h & OXYGEN, NASAL”
C- (TYPE “CARD”) - Select “Cardiac Monitor” q1h
C- C SPINE COLLAR- Only for TRAUMA patients- should be placed BEFORE examining the patient.
Non-emergent (not life-threatening): Directly go to physical exam
3. Physical exam
Complete physical exam:
If stable and pt has broad generalized signs and symptoms, do a complete physical exam.
Focused physical exam:
If unstable, ALMOST ALWAYS FOCUSED. = GEN APPEARANCE + cardio/respiratory exam +/- system-specific
exam (ie abdominal distress= examine Gen app + CVS + RS + abdomen + rectal). This will help create your initial
differential diagnosis.
Later in the case as you are waiting on orders, make sure to complete the physical exam. You can use the time spent
waiting for orders to complete the physical exam.
As you start the examination, the orders that you placed as emergency orders will give you updates.
Click “Continue” if the vitals are good.
Click “Stop “if you want to go and place orders before proceeding with the examination.
4. Orders: Labs/Studies
Geared towards diagnosing and excluding differential diagnosis [IBUOP mnemonic]
Images (US, XR, CT, MRI, Echo)
Blood work (CBC, BMP, Mg, Phos, TSH, A1C, ABG, Blood culture)
Urine (UA, urine culture, Ketone, Urine toxicology)
Others (Cardiac enzymes, EKG, peak flow, FOBT, biopsies, LP)
Pregnancy (serum/urine b-HCG - for all reproductive age women)
At this point, you can advance the clock to see results.
5. Locations
Depending on the situation, if they are coming to your office, you can send them home while their test results come in. Make a follow-
up appointment in 1-2 weeks and then move to next orders depending on your test results.
Home
Office
ER
Wards
ICU: shock, respiratory failure, DKA, MI, refractory electrolyte issues, acute AMS.
6. Are you admitting them to the ICU or the Ward?
If you are admitting them, then you must think of the following orders to always put in.
A: Antibiotics + Ambulatory or
B: Bed rest
C: Stress ulcer prophylaxis (PPI)
D: Diet (diabetic, low salt, NPO, regular, cardiac)
D: DVT prophylaxis (LMWH, compression stockings)
E: Elevate head end of the bed
F: Foley and “urine output”
G: Gastric tube if needed
Vitals (Q1, Q4, Q8)
Routine labs (e.g., BMP, CBC q24h)
Symptom management
Pain - Morphine, NSAIDs, or acetaminophen
Nausea – Zofran, Phenergan
Antidiarrheal – loperamide
ICU Orders:
1. Elevate head end of the bed ( to prevent aspiration pneumonia in ICU setting)
2. DVT Prophylaxis ( order compression stockings or TED stockings)
3. Stress ulcer prophylaxis ( orders PPI such as pantoprazole)
4. Activity ( Bed rest, ambulate in room)
5. Output monitoring ( Foley if obstruction or if unresponsive/ delirium)
6. Diet ( NPO, Diet or NG Tube if disoriented)
7. Neurochecks if disoriented
8. Suction airway if comatose or disoriented
7. Treatment
This will depend on what is needed for that particular case. However, when you need to do surgery, you have to order specific orders
prior to the surgery every time. And remember to consult the specific specialty before treatment is made, unless an empiric abx is
required.
Surgery pre-op orders: NICE PT (on surgery table):
NPO, NSS
Informed consent
Cefazolin (+ any other antibiotics!)
ECG
PT/PTT
T&C
Name of the surgery (if surgeon doesn’t accept, you’re probably missing some tests necessary to qualify them for
surgery, or they don’t need surgery).
If female and pregnant, Rh type should be done as well.
8. Reassess – Check in with the patient
You will do an interval history and a focused physical exam to check in on the patient when they are admitted or when they return
for a follow-up exam at your office. This will let you know if they are getting better or they are getting worse.
9. Screening and Counseling
Always look to see if you need to order any screening tests depending on the age and lifestyle (based on basic info). Type “Counsel”
Screening examples: pap smear, colonoscopy, mammogram, vaccines (select vaccin - flu, zoster), hep C screening,
PPD.
Counseling examples: smoking, exercise, medication compliance, alcohol/drug use (alcoholics anonymous), seat belt,
safe sex, diabetic teaching/foot care.
10. Final Orders
At the 2 minute mark, you can do the following:
Add or discontinue any needed orders to be done NOW (at the simulated time).
If you are discontinuing any orders, make sure you’re not discontinuing any stabilizing orders if you’re
still on “day 1” of simulated time.
Add any follow-up orders (e.g., monitoring labs like A1C or INR or USPTF guideline screening) to be
done LATER.
Can enter multiple counseling orders for NOW. (FYI - cannot do multiple counseling orders during the case
itself).
Other random notes:
Approach to Office Cases:
1. Complete physical examination
2. Symptom treatment + Routine + Specific orders.
1. IBUOP:
1. Images (XR, US, CT, MRI, Echo)
2. Blood work (CBC, BMP, Blood culture, TSH levels, ABG)
3. Urine (UA, urine culture, Ketone, Urine toxicology)
4. Others (EKG, Cardiac enzymes, peak flow, biopsies, LP)
5. Pregnancy (b-HCG - for all reproductive age women)
3. Urgent - send to E.R.
1. Example: pneumonia with + CURB65 (confusion, uremia, RR > 30, SBP < 90, Age > 65)
2. Pyelonephritis or PID w/complications (e.g., n/v so need IV meds).
4. Nothing urgent - Send the patient home and follow up after the report time.
5. Results
1. Normal – Reassure the patient.
2. Abnormal – stop the clock + order tests or treatment +/- change location to E.D. if admission needed.
1. If you stop the clock, you have to reschedule the new appointment,
6. Follow up at appropriate duration and do an interval history and focused physical.
7. At the two minute screen:
1. Procedures / surgeries that weren’t placed to be done NOW.
2. Add any follow-up orders (e.g., monitoring labs like A1C, TSH, or INR, medication side effects monitoring,
following drug efficacy, or USPTF guideline screening vaccinations) to be done LATER.
1. Switch IV to PO meds if going home.
2. Diet orders
3. Can enter multiple counseling orders for NOW. Choose the ones relevant to the case first, then routine (FYI -
cannot do multiple counseling orders during the case itself).
4. Cancel unnecessary orders at that point in time.
8. Final Diagnosis.
Approach to Emergency Cases
1. First stabilize the patient (MAVOC + Fluids)
M - (TYPE “MOR”) Morphine IV (can be given in all pain patients EXCEPT those in HYPOTENSION as
morphine leads to peripheral vasodilatation- give Fentanyl/ Ketorolac in that case).
A - (TYPE “ACC”) Select- “Access IV” and “Accucheck Glucose”
V - (TYPE “VIT”) Select Vitals q1h
O - (TYPE “OXY”)- Select “PULSE OXIMETER q1h & OXYGEN, NASAL”
C - (TYPE “CARD”) - Select “Cardiac Monitor” (+/- EKG)
C - C SPINE COLLAR- Only for TRAUMA patients- should be placed BEFORE examining the patient.
2. Focused physical examination.
3. Basic/Specific tests: order the tests alongside the above MAVOC tests to decrease simulated time.
IBUOP:
1. Images (XR, US, CT, MRI, Echo)
2. Blood work (CBC, BMP, Blood culture, TSH levels, ABG)
3. Urine (UA, urine culture, Ketone, Urine toxicology)
4. Others (EKG, Cardiac enzymes, peak flow, biopsies, LP)
5. Pregnancy (b-HCG - for all reproductive age women)
4. Fill the time: Complete the physical or do a follow-up history to finish the initial H&P so time will pass and tests will
come back (or just click advance the clock to the point of the most important test you’re waiting on if you’ve
completed the others).
5. Decide whether to “stop the clock” depending on the results and treat as needed.
6. Specific Treatment:
Change treatment interventions based on test results.
If surgery, put in pre-op orders.
Surgery pre-op orders: NICE PT (on surgery table):
NPO, NSS
Informed consent
Cefazolin
ECG
PT/PTT
T&C
Name of the surgery (if surgeon doesn’t accept, you’re probably missing some tests necessary to qualify them for
surgery, or they don’t need surgery).
If female and pregnant, Rh type should be done as well.
7. Location: Ward vs. ICU with appropriate orders.
A: Ambulatory or
B: Bed rest
C: Stress ulcer prophylaxis (PPI)
D: Diet (diabetic, low salt, NPO, regular, cardiac)
D: DVT prophylaxis (LMWH, compression stockings)
E: Elevate head end of the bed
F: Foley and “urine output”
G: Gastric tube if needed
8. At the two minute screen:
Follow-up orders (e.g., monitoring labs like A1C or INR, medication side effects monitoring, following drug
efficacy, or USPTF guideline screening vaccinations) to be done LATER.
1. Switch IV to PO meds if going home.
2. Diet orders
3. Discharge patient if appropriate
Can enter multiple counseling orders for NOW. Choose the ones relevant to the case first, then routine (FYI -
cannot do multiple counseling orders during the case itself).
Cancel unnecessary orders at that point in time.
9. Follow up for a week.
10. Shift to Home & follow up.
11. Final diagnosis
Misc Notes from Archer Videos:
Write the framework on the whiteboard on the morning of the test date (MAVOC, IBUOP, NICE PT for surgery, admit
orders)
Click “obtain results” to advance the clock forward.
Stop the clock function: Decide whether to “stop now” (e.g., need to address ventricular fibrillation or hypoglycemia
- put the treatment orders in) or “continue” (non-urgent, do not need to address now).
Pay attention to the ordering of the orders – e.g., get the CTA before the cardiothoracic surgery. Don’t group the
orders together since the time that it will return may vary.
The software does NOT score what you write (e.g., reason for consult); it only analyzes the orders you placed.
Don’t enter blood cultures and antibiotics together. Blood cx first, advance clock by 1 min and then antibiotics. This
is very important in case of Infective Endocarditis where blood cultures x 3 must be obtained 30 minutes apart before
starting antibiotics – cultures here dictate management decisions further in that case
Discharging the patient: If the case ends before you get a chance to discharge the patient and the patient is ready for
discharge, write discharge patient at the end order.
Other Notes:
1. Simulated time:
1. Only advances with: advance the clock button, doing a physical, and doing an interval history.
1. Important in emergency situations (e.g., solve the case within 1 hour of simulated time).
2. Completing the physical or doing an interval follow-up history is an efficient way to “fill the
time” while you are waiting for results to return.
2. What is scored?
