Hi there. Here’s whatever is worth of my USMLE Step 3 experiences. CCS cases in particular. Sure hope they’re of some help!
If you are crossing time zones, try to get to your venue a couple of days earlier so as to adjust. USMLE is long, tough and requires a lot of concentration.
The first day is tough. That’s my feeling. Seven 1 hr. sets of MCQs. Either way, it’s 1 min. 15 secs. for a question and by Jove, you’ll need it. The questions are long.
If I were you, I’d read the answers first. Makes it easier when you scan the question. For instance, the real choices may be about the required ethical decision. But the question will be full of technical fluff.
Concentrate on Office/Satellite settings. That’s about the size of the exam. Those with experience in family practice will just love Step 3.
Second day – three shorter sets of questions. CCS follows. And CCS is what this posting is really about.
CCS is actually fun! Immensely enjoyable. Nine cases on the whole, easily diagnosable. How u manage them is the crux of the matter.
You must do the five samples given by USMLE. Also do the practice scenarios and think through the case. This is before doing the real exam. A MUST.
At the beginning you’re given a very short introduction. Something like “a 45 aged white man comes with a complaint of severe chest pain. Then you’ll be given the history of the complaint and additionally PMH, Allergies, DH, ROS and FH etc. You have no alternative except to read through all the material.
Before you move on, these are what you should do:
- Try to come to a narrow differential diagnosis – even before the physical exam
- Note down any allergies (in case you administer the wrong Rx accidentally).
- Note down risk factors like obesity, hypertension, smoking etc. You could get extra points if you counsel the patient on these at the end of the case.
- If pertinent and necessary, you can sign off with a order for some sensible screening tests such as pap smear or mammography etc.
Right. Now that you’ve gone through the complete history and come to a conclusion on the differential diagnosis, your next important query would be:
Is the patient stable? That is, is there anything to be done immediately? If the answer is yes, no point in doing a physical. It would be inappropriate. Imagine you’re on the spot. You’ve a patient with severe chest pain. Would you waste your time doing a through physical? No! You’d straight away go in for oxygen, iv access (for pain relief or otherwise), pulsox, EKG and portable CXR and ABCs. If there is any indication, don’t forget to get tests such as ABG, serum glucose, PEFR and urine analysis done. These are just routine that you might just forget them.
Another essential point; what if this took place in an ‘office’? Application of oxygen and perchance an IV line might be possible, but you’ll soon have to do a move location to an ER for further management.
If the condition of the patient is severe and the situation warrants it there will be justification in carrying out all these emergency actions before the actual physical. Once a semblance of normalcy is established move on to the PE and click on the systems that you wish to examine. A cardio/respiratory/abdominal exam is essential and shouldn’t be missed. Also any other appropriate ones.
Once you go through the PE findings, your differential should be narrowed down even more further. With the coming in of the EKG, the CXR and the blood results, you should have a preliminary diagnosis.
This is when you start on a specific line of management.
If you had ordered a number of tests and are waiting for the results, you can try to obtain those results earlier. In case your method of management is correct, feedbacks like “the patient is more comfortable” or “is less breathless” will come in. In case you are wrong, the feedback would more possibly be “your patient’s breathless is increasing”, etc.
Keep firmly in mind the venue. If your patient is unstable, that is he/she is having acute heart failure, DKA, MI or Pneumothorax, move him/her to the Intensive Care Unit (ICU) immediately. In the US of A, pneumothoraces and DKAs are usually taken care for in the ICU. If necessary, a central line, or an arterial line or a PA catheter might be given. If immobile, keep heparin in mind.
If the patient is in your consulting rooms, with some minor complaint, there is no necessity for a rush. You can take your time to examine your patient. You can then order any tests that are relevant. And if you need those results to confirm your diagnosis, get your patients to undergo them without any delay.
The CCS will show you when the results of the tests that u ordered will be made available. In a consulting room, blood tests will take about a day. You can send the patient home with a pain killer, if necessary, and ask them to come back with the test results.
Specifically in a consulting room situation, you may have to see the patient a couple of times over a week or two or more to see if he/she is getting better. So, if for instance, it is a patient with Iron deficiency, don’t just prescribe ferrous sulphate and some counseling and forget about them. But do counsel them if required. For instance for drug compliance or cessation of smoking.
Location change is also important in the reverse. If your patient in the ICU is much better, shift him/her to the general ward.
Over-treating will not get u extra points. You just might end up losing some. Like, for example, if you do an unwarranted expensive or invasive procedure.
In a CCS setting you are the patient’s primary physician. Usually you’ll not be allowed to perform an specialized procedure like evacuating a subdural hematoma. If such a procedure is deemed necessary, you’ll have to refer the case to the specialist concerned.
Clicking “consult” in the orders page will list out the choice of specialists.
If you do not have sufficient grounds for a referral, the specialist will not put in his appearance. For example, for a cough, you’ll most probably get a refusal from the Pulmonary Specialist. But if you did an imaging on the chest that turned up a discrete lesion, not only will the pulmonologist but also the oncologist will evince interest. The point is, have solid evidence, like imaging. Once the problem is identified then the operation on the patient can be carried out.