USMLE CCS step 3 Tips and Tricks discussion

[steveme]

CCS is considered very important for passing Step 3. Despite this, most of us do not place enough emphasis on this. There are so many things we do not notice on software because of not knowing or not practicing enough. Often what our mind does not know, our eyes do not see. I am starting this thread hoping to have a dynamic discussion on CCS to keep myself involved and updated. Most strategies posted here are from my own understanding and what I gathered from going through ********** videos and Step 3 online forums.
Please feel free to contribute to this thread.

CCS tip #1
Anything that you manually type in to the blank box is not picked up and scored by software.
1. Diagnosis is not scored
2. Reason for consultation that you type in the box is not scored but you must state reason for consultation by selecting and placing an order

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[steveme]

to answer my own questions - unlike the UW answer choices, on the real exam there does not seem to ever be an option to de-escalate IV orders to PO, follow up in office. the office cases stay in office and the hospital cases stay in the hospital. its very obvious when the "cure" has been administered and the case ends.

@witzelsucht, you can deescalate the orders on 2 min screen. You just need to d/c IV and put a PO order. You can use change location button to move patients from one location to another when needed.

 

[steveme]

When to Intubate on CCS ?
Please realize that you almost never get to intubate on the CCS. Most of the times, patient's condition improves following appropriate non-invasive measures. After intervention, you must put in monitoring orders at certain time intervals to check for improvement in patient status ( Neurochecks q1h in coma patients, Pulse Ox/ Clinical follow up q1hr in respiratory failure patients etc)
In one of the cases in ********** videos, Dr. Red clearly states "Intubation when not necessary" will be regarded as an extremely invasive measure by the software and will be subject to negative scoring.

Archer recommends Non-Invasive ventilation/ oxygenation ( if not contraindicated) followed by monitoring in respiratory failure cases before making a decision on intubation. Sometimes it appears like the case is headed towards intubation but in reality, it is not.
The software is not testing your ventilator management skills. It is looking for whether or not you will attempt noninvasive ventilation/ oxygenation before resorting to invasive intubation.

Non-invasive measures of oxygenation include nasal cannula, venturi mask, Non re-breathers mask ( on CCS, you just select O2 ).
Non-invasive measures of ventilation include NPPV ( noninvasive positive pressure ventilation) methods like BIPAP, CPAP.

I did have hard time applying these on the software in the beginning because when doing UWorld cases, you almost never get to understand proper concepts that dictate emergency interventions. Archer says too many students "invade" patients on the CCS unnecessarily and this is one of the reasons for getting a low performance on CCS despite doing most of the case very well. I do think this is true.
So "DO NOT INVADE" unless you are certain that your non-invasive measures have failed.

 

[GoSpursGo]

Guys, general discussion is fine, but please remember that posting links to for-profit resources is not allowed.

 

[MSTP18]

few questions, 10 days til exam:

how bad can you do on CCS and pass if you are looking at a solid MCQ score?

assuming you hit the critical actions (needle decompression, ct angio for dissection, mag for eclampsia), how much does the disposition stuff matter? if you leave them in the ED or ward, don't de-escalate orders, etc. does that even really matter? the office followup stuff is also bothering me. ive been bringing the depressed people back for like q1 week office visits. does that negatively impact your score or as long as you have some followup its ok? another thing on the depression case - i sent a CBC/vit D/tsh, cbc was normal so i didnt bother with B12 level. minus points? uworld seems to think so. im an ED resident so this stuff is all new. what about stat vs routine labs? didnt do a boob exam on depressed lady, that can't effect your score much, right? it seems like the scoring is mostly based on critical actions not inefficiency...

Bruh, I'm a path resident. I haven't even been in the same room as a patient in a year.

 

[steveme]

@MSTP18, the CCS software functions much differently than in the real life. Orders and procedure do not get done until you advance the clock - it is more like a game and the more you practice, the more you get perfect in it. If you placed the general set of orders, you end up getting some clues to the case upfront. By placing monitoring orders, you tend to get automatic updates intermittently alerting you regarding the direction the case is going.
I find CCS more fun compared to reading theory.

 

[DocSpy332]

Hey guys, I just wanted to share my experience regarding the CCS section of step 3 and what helped me go through it.

I did only UW CCS. But I went through them three times.

Here you can find a good mnemonic-series to get the low hanging fruits. I want to make it clear that none of this is mine I just found it, used it and I think it's worth sharing with future candidates.
-------------------------------------------------------------------------------------------------------------------------------------------------

Emergency orders (by going through UW you will understand in which cases you need to put them): POLICES, MONA-A, Vitals q?h:
Pulse oxi, Oxygen, saLine, Iv access, Cardiac & bp monitor, ECG, Sugar (=fingerstick glc),
Morphine, Oxygen, Nitroglycerin, Aspirin, Antidotes (eg Naloxone, B1, etc... )

Routine tests (in order to be sure that you have ordered the common ones): A CBC LFTS ICU PAX
Abg
Cbc, Bmp, Cardiac enzymes
Lfts, Lipid panel, FOBT, TSH, Stool exams, Iron studies, Immuno-any, Imaging-any, Cultures, UA, Pap, PT/PTT, Pregnancy test, PFT, Amylase-lipase, X-ray's

Always! Comfort fever, pain, NV, constipation (by going through UW CCS you will learn how)

Admission orders (always consider when admitting): PANIC-R
PPI, Activity (eg Bed rest), NPO (ie diet in general), Inputs/outputs, Compression stockings, repeat any tests (eg accu, neuro-checks, cbc, vitals..)

Preop orders (always do if you proceed to surgery): NBC-PT/PTT
NPO, Blood T & C, Consent, PT/PTT
------------------------------------------------------------------------------------------------------------------------------------------------------

Hope that helps!

 

[steveme]

Just FYI, Final diagnosis screen removed from software.
Just like reason for consult that you type in, typed-in diagnosis has never been scored.
United States Medical Licensing Examination | Announcements

 

[steveme]

I'm currently doing the Uworld CCS cases and I've just come across two cases in which DVT/PE is treated with warfarin and heparin bridging. Now where I practice, uncomplicated DVT/PE is just treated with apixaban/rivaroxaban/whichever right off the bat, sometimes with prior LMWH/UFH if there is any uncertainty as to the degree of hemodynamic stability. Warfarin would not receive consideration unless specifically indicated. Are the cases and recommendations in Uworld outdated or is this the standard of care in the US? Any americans care to chime in?

@AnalisCanalis - Yes, I agree that UWorld CCS is outdated with CCS guidelines and even with regard to turn around times of tests on the software. When USMLE updated their order times and case flows 2 years ago, UW ccs software did not automatically update those turn around times so there are some discrepancies. There are several issues with consults in UWorld. The exact software is at www.usmle.org and I would definitely practice on that several times. If you are looking for exact CCS software being used to demonstrate large number of CCS cases with guidelines, ********** cases videos are excellent and up to date with guidelines and they demonstrate on the exact exam software.

With regard to your question regarding DOACs, even the official exam software from usmle.org is not uptodate with all the newer anticoagulants. But it helps to know that they have updated their list with Xarelto or Rivaroxaban and this can be used instead of Warfarin. They expect us to do that because warfarin is no longer preferred choice for a reason . There is no option for Apixiban or Dabigatran. I obtained this info from ********** and I tested it myself on the official exam software and found that this info is correct.
Similar to how Archer demonstrates high-yield cases on original exam software, the best way is to download the USMLE step3 CCS software from usmle.org and put in these orders to test yourself. This is the best way to practice rather than just doing UWorld

@AnalisCanalis - brought up a great point. USMLE - DOACs on CCS
This is the exact reason why one should practice thoroughly on the original exam CCS software downloadable from www.usmle.org

 

[steveme]

Please note that UWorld CCS is missing some crucial updates used in USMLE Step3 CCS Software at www.usmle.org.
This can change your approaches and affect the score.
Be mindful about new standard guidelines and make sure you practice on the exam software downloaded from www.usmle.org .
********** is also immensely helpful in this regard as the original software was used in their CCS Cases videos so all new guidelines with new drugs are applied in their explanations.

Rivaroxaban is on the original exam exam software but it's missing on UW and UW is still teaching the old heparin bridging method. This can mess up your thought process obviously. As we all know, newer anticoagulants like Rivaroxaban have been used for quite sometime as a standard of care in the setting of DVTs/ PEs. This is due to reduced risk of intracranial bleeding compared to warfarin. If you are using this DOACs, you do not need to really bridge with warfarin.
The only exception where warfarin is still preferred in DVT setting is if there are DVTs associated with APLA syndrome (Lupus anticoagulant) where DOACs are not yet tested. Archer explains all these cases well.

Practicing on the actual exam software will enable you to figure out how the software responds to the input based on standard guidelines.
Good luck!

 

[c0pycat]

Please note that UWorld CCS is missing some crucial updates used in USMLE Step3 CCS Software at www.usmle.org.
This can change your approaches and affect the score.
Be mindful about new standard guidelines and make sure you practice on the exam software downloaded from www.usmle.org .
********** is also immensely helpful in this regard as the original software was used in their CCS Cases videos so all new guidelines with new drugs are applied in their explanations.

Rivaroxaban is on the original exam exam software but it's missing on UW and UW is still teaching the old heparin bridging method. This can mess up your thought process obviously. As we all know, newer anticoagulants like Rivaroxaban have been used for quite sometime as a standard of care in the setting of DVTs/ PEs. This is due to reduced risk of intracranial bleeding compared to warfarin. If you are using this DOACs, you do not need to really bridge with warfarin.
The only exception where warfarin is still preferred in DVT setting is if there are DVTs associated with APLA syndrome (Lupus anticoagulant) where DOACs are not yet tested. Archer explains all these cases well.

Practicing on the actual exam software will enable you to figure out how the software responds to the input based on standard guidelines.
Good luck!

Regardless of the newer guidelines regarding which anticoagulant to choose...I do believe that if you do the heparin-warfarin bridge on a case in the real exam, you will still get the points for the case. This is a standardized exam and so not everyone will be aware to put let’s say rivaroxaban on the exam. The software will mark it correctly if you do the heparin-warfarin bridge. I disagree with your point regarding following the newer guidelines. This exam is taken by all that are eligible to take it...practicing vs non practice and not everyone knows the latest guidelines. The software will test you still on how to properly manage a case with either DVT or PE but you won’t be loosing a case simply because you put heparin then warfarin instead of rivaroxaban.

 

[steveme]

Hi Brunette ...I agree with you that system will still give you some score for using LMWH bridging with warfarin.
ACCP recommends the use of direct-acting anticoagulants over warfarin for VTE treatment in patients without cancer. So DOACs are preferred by guidelines.
Warfarin with heparin bridging is an acceptable alternative on the software however, this approach is not just old but is time intense, needs more clock maneuvering, needs INR checks and unnecessary burden on a step 3 resident who is trying to get the best score. It's possible that we may miss some of steps in sequence of clock maneuvering, repeat inr Checks, making sure INR > 2 and then d/c heaprin --- this sequence is time consuming, fraught with complexity and not even the preferred guideline. Starting DOAC ( Rivaroxaban) does not need bridging, no clock maneuvering - simple step and high score!! Which one would you choose?

So choosing something which is simple to manage on the software and is a preferred guideline and fetches you the highest score is more logical from exam prep strategy perspective. My point was that UWorld has not adjusted and updated their software similar to the exam software to teach the latest strategies and best approaches to score well on exam. Practicing on the true exam software yields the best results.

 

[steveme]

Someone asked me a question today..... Should we check Fecal Occult blood or stool guaiac in a patient with MI before initiating Heparin and plavix?
What do you guys think?

 

[steveme]

Someone asked me a question today..... Should we check Fecal Occult blood or stool guaiac in a patient with MI before initiating Heparin and plavix?
What do you guys think?

Ok...I am used to some books/ courses telling me that we need to do FOBT before initiating anti-coagulation in VTE and MI etc . I have seen that in UWorld cases. Please do not attempt that in CCS scenarios where the patient comes to ER with chest pain. Prioritizing the next step using risk/benefit analysis is the very foundation of clinical judgement.
If he/she has PE, you should go ahead and start anti-coagulation rather than subjecting this distressed patient to a rectal exam. Such unnecessary invasive exam in a distressed patient may cause you to lose some score ( source: **********).
Even if you found occult blood in the stool, would it change your management? It would not! Acute PE or Acute MI is more evil than "occult" blood
Anti-coagulation in acute VTE or ACS is contraindicated only when there is "gross" or "symptomatic" bleeding not when there is just "occult" blood.
Here is more information : Utility of Hemoccult Testing Before Therapeutic Anticoagulation in Venous Thromboembolism. - PubMed - NCBI

 

[steveme]

Do you ever get to intubate on CCS? If so, are you required to set up Vent settings? What modes of ventilation need to be tried before invasive intubation?

 

[trax82]

Two questions about CCS:

1) Is the overall objective to get to the correct diagnosis and treatment as quickly as possible? Or is it to be as thorough as possible and just be going in the right direction?

2) If your patient requires surgery, are you supposed to order the surgical procedure itself? (e.g. Appendectomy, Colectomy) Or do you just order all the pre-op tests (PT/PTT, NPO, etc.) and place a surgery consult?

 

[steveme]

Two questions about CCS:

1) Is the overall objective to get to the correct diagnosis and treatment as quickly as possible? Or is it to be as thorough as possible and just be going in the right direction?

2) If your patient requires surgery, are you supposed to order the surgical procedure itself? (e.g. Appendectomy, Colectomy) Or do you just order all the pre-op tests (PT/PTT, NPO, etc.) and place a surgery consult?

@trax82 ..sorry i missed this. Here are my answers:

1. Overall objective depends on the location : ER vs. Office. In ER, it is more about how fast vitals were stabilized and how fast stabilizing intervention was undertaken. Here simulated time matters the most and if the action is taken in a shorter simulated time, score is higher.
In a stable office case or inpatient case, the goal is not just making diagnosis but also taking care of sequencing, monitoring ( follow-ups, monitoring treatment efficacy and side effects) including your responses on 2-min screen.

2. Yes. But as shown in **********, you must place surgical consult first and then wait until you get a response "patient will be accepted for surgery" . Software like UWorld are filled with errors and do not accept patient for surgery even when surgery criteria are met so that can be confusing. But on the actual exam software, you will receive a message " "patient will be scheduled for surgery, proceed with medical management" if you have met criteria for surgery. Meeting the criteria for surgery varies from case to ca. In the case of thoracic aorta dissection, criteria for surgery can be as simple as proving that it is in ascending thoracic aorta by getting a CT Chest or TEE timed PRIOR to asking surgery consult --- this is called exact sequencing.
When you sequence that way, your result comes before surgeon sees patient - you then acceptance message. Once you get acceptance message, place pre-op orders - TYPE/CROSSMATCH; NPO, IV NS, PT/PTT, NAME OF SURGERY ITSELF ( Source: **********) .
So much goes in to this! But once you know the strategy, it is very easy to play with actual exam software. Practice on USMLE exam software materials and use ********** which is where I got most of the above tricks from.

@trax82 , here is a sample Step 3 CCS video - it's one hour only though but gives some insight in to timing, sequencing etc.

 

[therealfinale]

Has anyone ever had a technical issue with a CCS case? In the middle of a case I had one that caused us to restart the computer several times, and I was not allowed (by the software) to finish that case. Prometric logged the issue. What happens next-will my exam score be adjusted accordingly?

 

[steveme]

Has anyone ever had a technical issue with a CCS case? In the middle of a case I had one that caused us to restart the computer several times, and I was not allowed (by the software) to finish that case. Prometric logged the issue. What happens next-will my exam score be adjusted accordingly?

I have heard about this issue happening in the past. Yes, your score should be adjusted to reflect that.

 

[Ready_User_1]

What's the word on physical exam? Is it kosher to just examine all systems everytime (other than outright emergencies)?

 

[steveme]

@Ready_User_1 ; In 10 min ER case scenarios, just pick 2 to 4 min physical exam that can help you diagnose underlying condition that led to unstable vitals. This is most suited for Resp failure and Shock case scenarios. In the routine cases, full exam in office makes sense. Unless it is an annual exam or makes sense to do it in the case presented, Rectal and Pelvic exam are usually skipped.

 

[Chingchang]

Hi there... I have used Archer rapid prep CCS which has 25 cases or so. I have prior attempt on Step 3 and would like more exposure to CCS specially want to have case flows and protocols similar to ********** demonstrations on the actual exam software. My question is ....should I do ********** intense prep which has 80 cases? How helpful is intense prep on top of archer rapid ccs prep? @steveme or any other experiences member here.. please help ! Thank you.

 

[Usmle aspirant journey]

Hello , pls help me with this doubt, if a negative result pops up eg. NAAT comes out positive and i know pt has PID but she is home , do I call her back or stop the clock and put orders ?

 

[steveme]

Hi there... I have used Archer rapid prep CCS which has 25 cases or so. I have prior attempt on Step 3 and would like more exposure to CCS specially want to have case flows and protocols similar to ********** demonstrations on the actual exam software. My question is ....should I do ********** intense prep which has 80 cases? How helpful is intense prep on top of archer rapid ccs prep? @steveme or any other experiences member here.. please help ! Thank you.

@Chingchang -- sorry, I have not logged-in here for a while. Personally, I did Archer Intense Prep CCS and found it to be tremendously useful. I have been able to truly master the CCS. There were about 75 to 80 cases in it and cases on actual exam are very similar. If you can afford, go for it! All the best

 

[steveme]

Hello , pls help me with this doubt, if a negative result pops up eg. NAAT comes out positive and i know pt has PID but she is home , do I call her back or stop the clock and put orders ?

@Usmle aspirant journey - it depends on whether this patient meets "criteria for admission". Determining the criteria for admission is crucial before you decide whether or not you need to change the location of the patient ( For criteria for admission in PID and other scenarios, watch ********** files).
The criteria for admission in PID are usually when a patient can not tolerate oral antibiotics ( due to nausea+ vomiting) and needs parental therapy or needs surgical intervention or is immuno-compromised. Here are some criteria for admission:

• when surgical emergencies (e.g., appendicitis) cannot be excluded;
• tubo-ovarian abscess ( needs surgical consult)
• pregnancy;needs inpatient therapy
• nausea and vomiting, ( can not tolerate oral antibiotics)
• unable to follow outpatient oral regimen ( non-compliance)
• no clinical response to oral antimicrobial therapy.

In such cases as above, stop the clock, change location to ward and then put IV antibiotics. If no criteria for admission are met, stop the clock and then add oral antibiotics on order sheet, counsel patient and reschedule appointment in 1 week for follow up. ( Source : **********)

These free slides belowwill help you on some strategies - when to stop clock/ changing location/ admission criteria etc, NOTE: These are FREE slides and I am not violating any copyrights.

 

[steveme]

How many of you are doing FOBT before you give anticoagulation to a patient in the ER with MI or pulmonary embolism ? Please Don’t

 

[Make Or Break]

How many of you are doing FOBT before you give anticoagulation to a patient in the ER with MI or pulmonary embolism ? Please Don’t

You mean to tell me I won’t get real life points if I do?

 

[steveme]

You mean to tell me I won’t get real life points if I do?

Doing FOBT in STEMI or Pulmonary embolism can get you negative scoring for more than one reason ( source: **********) :-

1. First and foremost, it is important to assess the Benefit vs. Risk ratio of any intervention whether in real life or on CCS. It is also important to analyze how obtaining information such as FOBT would in anyway change the anti-coagulation management in an Acute MI or PE.
Even if FOBT is positive, you will not be holding life saving anti-coagulation in these priority cases.
Because "occult bleeding" is not a contraindication to anti-coagulation in these cases. ( gross bleeding with unstable vitals is but not occult bleeding).

2. Delaying life-saving treatment in ER in these cases waiting for FOBT etc is detrimental to your CCS score. Your clock is ticking on simulated time.

3. FOBT/ Rectal exam is invasive and to do something like that in an unstable patient or in a patient with severe pain from MI/ PE etc is insane. Not just that, it will also carry negative score.

Now if there are some courses that recommended you to do FOBT before anti-coagulation in an acute setting in the ER, please disregard that garbage because these are some of the reasons how lot of people are scoring low on CCS despite them thinking that they have managed the cases really well. I agree with ********** reasoning above.

 

[steveme]

Let's list criteria for admission in Pneumonia ? Anyone?

 

[c0pycat]

Let's list criteria for admission in Pneumonia ? Anyone?

CURB-65
Confusion
Uremia >19
Respiratory Rate >30
Blood pressure <90 systolic , <60 diastolic
65 or above, age
Any 2 of the above qualifies for admission

 

[steveme]

CURB-65
Confusion
Uremia >19
Respiratory Rate >30
Blood pressure <90 systolic , <60 diastolic
65 or above, age
Any 2 of the above qualifies for admission

Absolutely! In the CCS, age itself can be presented without CURB in an Outpatient visit for Pneumonia symptoms. So its important to recognize age alone can be a criterion for admission, get that CXR in the office and then send them directly to the ward as an admission. Do not have to send via ER

 

[Asa17]

Hi, thanks to you everyone for your inputs here . I am currently preparing for step 3 and I am doing the ccscases now . I have noticed that in ccscases, placing emergency orders before physical exams in a distressed patient is evaluated as out of sequence. So is it better to do physical exams first in all cases before proceeding to place orders like oxygen , pulse oximeter in a distressed patient?

 

[steveme]

Hi @Asa17 , I have posted this before but maybe my post got submerged in the thread. It is very crucial to note that CCSCASES is promoting very wrong scoring protocols. Unfortunately, CCSCASES.COM has been able to sell themselves showing this wrong scoring method claiming this is how they differentiate themselves from UWORLD and **********.

A couple of friends of mine have committed blunders on their CCS because they were misguided by their dubious scoring system and then, ended up failing. I can give you several examples apart from the one you mentioned

1. CCSCASES software wants you to put screening orders on ED patients as well on 2 min screen. This is dangerous in unstable patients and in case of stable patients, this type of approach makes you focus on things you do not need rather than what you actually need on a 2-min screen. CCSCASES sequencing with regard to many cases on their system is also incorrect. I can not post many of their wrong cases here due to copyright issues but you should be aware of their errors. For understanding what you need to place on a 2-min screen for a variety of cases and how to best use simulated time in 10-min cases and also, how to sequence the orders appropriately, watch **********.
2. As you mentioned, CCSCASES allots a score to certain wrong interventions and unnecessary screening orders and to some other non-essential orders. When you are being scored for this nonsense, you get the impression that these must be placed on the exam. When you end up doing that, you lose valuable time on a 10-minute case during which other orders could have been placed. If the order that CCSCASES gave you a score for, is unnecessary and also invasive, you will end up getting a failing score on that case because unnecessary INVASIVE measures get a negative scoring on the exam. For example; you have an MI patient and you added a screening colonoscopy on a 2-min screen without regard to simulated time, you will get a negative score for placing a stressful intervention in the immediate post-MI period. There are several cases like that on that CCSCASES software which is totally misleading an unsuspecting step3 aspirant.
3. Placing emergency orders in a distressed patient before a physical exam is a correct approach. So, what you did was absolutely correct. If you are being penalized by this wrong and misleading ccscases software for a correct approach, you are going to commit this wrong sequential strategy on the exam which can be dangerous to patients and lead to losing valuable simulated time.
Maybe it is time to stop using that erroneous software to prevent yourself from being misguided. PLEASE DOWNLOAD ACTUAL EXAM SOFTWARE FROM USMLE.ORG and practice using the methods taught by **********.
Please follow the criterion standard ********** strategies to get this correct approach of Diagnosis, Location, Timing, Monitoring, and Sequencing where Archer uses exact USMLE software to demonstrate the cases. Archer shows protocols for many important cases and explains every step using the official exam software in their workshop videos I think that is the best for learning CCS and for practice, you can use always use additional UWorld software because at least, UWorld will not penalize you for the correct approach by giving you incorrect scoring since UWorld will not score you.

I wish you all the best. Please feel free to ask me any questions.

 

[steveme]

Received a message from a few here to share the 100 high-yield CCS cases. Here is the 100 cases list taken ********** Intense prep files.

1. DKA
2. Pulmonary embolism
3. Endometrial carcinoma
4. 1 day old Newborn Down’s baby presenting with vomiting/ Duodenal Atresia
5. Motor vehicle accident with splenic rupture
7. TIA
8. Acute Hepatitis A
9. Secondary Hypertension, Hypokalemia – adrenal mass
10. Minimal change disease: The child had scrotal swelling.
11. Constitutional growth delay in African American kid
12. Pericarditis
13. VSD
14. Acute MI
15. Osteoporosis with compression fractures
16. Gastritis secondary to NSAIDs use
17. New-Onset DM type II
18. Pregnancy
19. Anaphylaxic reaction/ Shock
20. Adrenal Mass/ Hyperldosteronsim/ Hypokalemia/ Young woman presenting with leg cramps & weakness
21. Heat Stroke
22. Ovarian Teratoma
23. Inflammatory Bowel disease
24. Vaginal Bleeding secondary to Fibroids requiring hysterectomy. ( Woman 44 y/o)
25. cervical cancer26. Turners syndrome
27. UTI/Sepsis – 76 Y/o woman sent from NH for evaluation of the altered mental status
28. Hepatic encephalopathy
29. Acute Cholecystitis
30. G6PD deficiency
31. Constipation, hypercalcemia, primary hyperparathyroidism
32. Pregnancy with asymptomatic bacteriuria
33. Back pain due to osteoporotic fracture – compression fracture
34. Bipolar disorder
35. Pulmonary embolism
36. Abdominal Aneurysm Rupture presenting with backpain/ No Hypotension at the presentation – Vitals stable, so you can get CT scan and then surgery consult.
37. Chlamydia trachomatis (in a male)/Nongonococcal urethritis
38. Erosive esophagitis/ GERD
39. Panic Attack
40. Acute Asthma Attack – 14 Y/O female with wheezing, Sob
41. Obesity in a teenager
42. Toxic Shock syndrome/ Tampon use
43. Hyperglycemia/ new-onset DM Type
44. fracture neck of femurs – 75 y/o female fell and sustained right hip fracture – Ortho consult, ORIF, fall prevention, hip protection devices, Osteoporosis screening, DVT prophylaxis
45. HIV with PCP and lymphoma
46. child abuse with subdural hemorrhage
47. Tylenol overdose
48. Heat Stroke
49. Acute PID
50. Tricyclic Overdose {40 y.o. Arab male with no history know brought in the ER by a neighbor with unconsciousness and unresponsive state – he had some depression as per neighbor (TCA TOXICITY)}
51. Acute pancreatitis
52. Child with intussusception
53. Woman with multiple sclerosis ( comes with weakness and has nystagmus on neuron exam)54. Septic pulmonary emboli in IVD abuser.
55. Stable Angina
56. SLE
57. Pregnancy in a 44yr old women
58. Bacterial Meningitis in an infant
59. Juvenile Rheumatoid Arthritis
60. Anemia secondary to colon cancer
61. Alzheimer’s Disease(had to rule out other causes of dementia before making the diagnosis)
62. 50 + y.o. M with epigastric pain (erosive gastritis, had h/o long term NSAID use) – Has age criteria for EGD.
63. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)
64. 4 yo. F with ANA +ve Arthritis65. 50 + y.o. F with high BP in office
66. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+
67. Acute manic disorder
68. UTI with 12-week pregnancy
69. chid abuse
70. acute diarrhea
71. Acute MI
72. CHILD ABUSE: 2 y/0 AA boy was brought with lethargy, CXR revealed multiple posterior rib fractures and CT head subdural hematoma —Child abuse, call child protection services and social work consult
73.) Eclampsia… presented with seizures and peripheral edema at 38 weeks of pregnancy.( Magnesium sulfate, induce delivery if still seizure – follow status protocol)
74) Uncontrolled DM type 2 – came with increased thirst and urination
75) HIV in a 25 y/o f with multiple partners – came with weight loss, fatigue, and cough. Do HIV test, viral load, genotyping. Then cd4 count.
76) Acute pericarditis.
77). Right upper quadrant pain, CXR– pneumonia – right lower lobe – community-acquired pneumonia
78) Dysfunctional uterine bleeding
79) Polymyalgia rheumatica
80) Trauma patient with cardiac tamponade
81) Pancreatic ca, an old man with fatigue, weight loss – exam shows icterus – go ahead with CT
82) 9mos old baby with fever unknown cause all tests including CBC are negative ( Roseolum infantum)
83) hypothyroidism in a man
84) Postmenopausal bleeding in a woman not on HRT/ benign endometrial hyperplasia85) cystitis
86) septic arthritis
87)gastric carcinoma
88)incomplete abortion
89)Atrial fibrillation
90) Diverticulitis
91) Dehydration/ Hypernatremia
92. 20-month-old African American boy brought for fatigue and lethargy to office/ Fe deficiency
93. Acute Bacterial Prostatitis
94. ALL in a 5-year-old/ 5 yr. old boy who came with weakness, disinterest in activity, and lesion on the leg.
95. Acute pericarditis – RX ( make sure to do an echo, don't do unnecessary pericardiocentesis if there is mild to moderate pericarditis without clinical or echocardiographic evidence of tamponade)
96. Osteoarthritis of the Knee ( if there is large joint effusion, always do arthrocentesis)
97. CIN III
98. Congestive heart failure in a post-op patient ( make sure they are not giving too much IV fluids in post-op setting, I/O monitoring, daily weights, Lasix, 2d echo, r/o MI, EKG, CXR, BNP – Lasix, if flash pulmonary edema, give morphine)
99. Hypercalcemia/ renal mass ( likely RCC) – Elderly man presenting with fatigue
100) Complete Heart Block - Woman coming with Motor Vehicle Accident/ only minor injuries on the arm, Vitals reveal Heart rate 38. - EKG shows complete Heart block

 

[steveme]

A couple of guys have emailed asking what is the best way to get maximum on CCS. The best way is to know the strategy in-depth, familiarize yourself with official exam software ( downloaded from usmle.org) by putting several orders in it to understand how responsive it is and how the orders show up and what the turn around time is while navigating the clock. Ensuring you meet Diagnosis, Location, Monitoring, Timing, and Sequencing requirements on each case and making sure you do not do unnecessary invasive investigations.

 

[Dr. USMLE]

Agree!

 

[steveme]

I would like to bring to your attention this thread For the love of all that is holy, PRACTICE YOUR CCS!!!!
this issue of acting based on "current" situation several times over last one year in this thread.
Once again I emphasize:- It is important to act on current simulated time scenario not in future except while ordering "follow up monitoring tests" using "calendar" option on 2 min screen.
This is crucial because none of these commercial software including UWorld teach you that. They guide you incorrectly to place orders on 2 min screen that does not pertain to the scenario and also, ask you to put screening orders etc. I am glad USMLE software is now reminding us with a popup. I am sure they are fed up with all invasive tests being placed on sick patients although the simulated time is not beyond a day. ********** has always mentioned and demonstrated this approach from beginning and as demonstrated in **********, the official exam software is best tool to practice on. One could use Uworld etc for extra practice but it doe snot help if there is no guidance on crucial scenarios like these and there are several. Of everything i have done for CCS, the best guidance I had was through ********** and I would follow ********** methods 100% because they have come out correct time and again.

 

[ranculus]

to answer my own questions - unlike the UW answer choices, on the real exam there does not seem to ever be an option to de-escalate IV orders to PO, follow up in office. the office cases stay in office and the hospital cases stay in the hospital. its very obvious when the "cure" has been administered and the case ends.

Thank you for posting this.

 

[idkididk]

So I'm going through the UW CCS cases right now, and some of my cases are ending early despite not getting them totally right. For example, the pregnancy case ended early without me ordering a transvaginal US (thought that would be the OB's order), and the ulcerative colitis case ended early without me ordering flexible sigmoidoscopy/colonoscopy (ordered CT abd instead). Does that mean I did well enough to pass but not enough for a good score?

 

[gjones33]

I just had a few questions that arent clear from the videos or the USMLE practice explanations

1) There are a bunch of different tests for many of the infectious labs. For instance with chlamydia I can get the urine ag, cervical culture, etc. Same thing for HIV, legionella, etc. I understand with TB/PCP for example which tests I order matter, but for the other ones, does it really?

2) On archer videos, they order blood cultures and abx at the same time, but on the usmle.org practice cases it specifically says that you get graded for drawing cultures before abx, do I need to fast forward the clock in between? If so, how long?

3) If I'm in the office and they need to be sent to the hospital, do I always send them to the ED first? Or can I go straight to inpatient/icu?

 

[steveme]

So I'm going through the UW CCS cases right now, and some of my cases are ending early despite not getting them totally right. For example, the pregnancy case ended early without me ordering a transvaginal US (thought that would be the OB's order), and the ulcerative colitis case ended early without me ordering flexible sigmoidoscopy/colonoscopy (ordered CT abd instead). Does that mean I did well enough to pass but not enough for a good score?

@idkididk Great Qs. Half the time these happen only on UW CCS because the software is not accurate to follow the orders you put in and correlate with the algorithm. You will also see UW always says continue medical management even after you call consultant and even when emergency surgeries are required. If you see they have not even updated the software for several years despite usmle.org changing everything to STAT...so that kind of changes your clock navigation strategy because it gives report times of tests much longer than what official software from usmle.org would give. Still you can use UWorld as a practice tool. I would suggest watching ********** to get best idea about actual official exam software , how best to make clock work for the case, and to apply evidence based guidelines for cases based on recommendations. Also, kmow all cases discussed there in Archer csc because they are often seen on the exam. Often doing Archer before practicing uworld will remove all the confusion about CCS.

Case #1. Pregnancy case typically is looking for diagnosing the pregnancy and placing antenatal work up. American Congress of Obstetricians and Gynecologists (ACOG) recommends that all women get a first trimester ultrasound -- typically, done at 7 to 13 weeks. It will carry a score. So here the key is whether your pregnant patient reached at least 7 weeks since her LMP --- you know this from history and from simulated time to which the software allowed you to advance clock without ending the case. If history mentioned LMP was 4 weeks ago and pregnancy test is +, you will place antenatal orders you will have to advance clock to at-least another 3 weeks before you get to ordering an ultrasound. You will get a lot of scoring for ordering prenatal tests and following results. If case ended before 7 to 8 weeks since LMP ( based on simulated time), you can use 2-min screen to select the order "ultrasound" and open the calendar and select a date to meet at-least around 8 weeks from LMP. Case done! And you have met most requirements. So use the 2-min screen to your advantage by selecting the date to order in future and meet the guidelines.

Case #2: UC case acute flare is usually treated symptomatically first and presumptively. CT may show colitis changes. But to know whether it is a UC in a patient with no prior established dx, we will need a scope. Scopes are reserved for those with mild to moderate symptoms. History and exam will tell you how severe the colitis is. Contraindications are mentioned in ********** that it is typically not advisable to do colonoscopy in patients with severe acute colitis, toxic megacolon, or those who can not have adequate bowel prep. If rectum is felt to be involved as in UC, flex sig may be helpful and is less risky than colonoscopy. If someone had severe acute colitis, a colonoscopy greatly places the pt at risk of perforation. So let the colitis settle and use your 2 min screen to select calendar and order colonoscopy 2 weeks after discharge. The management that gets a score is really labs, stool tests, other exclusion diagnostic studies, empiric treatment and then 2-min screen orders.

 

[steveme]

I just had a few questions that arent clear from the videos or the USMLE practice explanations

1) There are a bunch of different tests for many of the infectious labs. For instance with chlamydia I can get the urine ag, cervical culture, etc. Same thing for HIV, legionella, etc. I understand with TB/PCP for example which tests I order matter, but for the other ones, does it really?

2) On archer videos, they order blood cultures and abx at the same time, but on the usmle.org practice cases it specifically says that you get graded for drawing cultures before abx, do I need to fast forward the clock in between? If so, how long?

3) If I'm in the office and they need to be sent to the hospital, do I always send them to the ED first? Or can I go straight to inpatient/icu?

@gjones33,
1. Selecting a test depends on its sensitivity, specificity, timing and invasiveness. Guidelines differ. In PID, you can get certain tests but in disseminated gonococcal the yield is quick and good with different type of tests from other sites like oropharynx.
Most often it may not matter on CCS software but keep any eye on report times. You want to order a test with quickest report time and yet sensitive so you can get some diagnosis and manage the case.
As you know, cultures take a long time. I did not check how long it takes for NAAT ( Nucleic acid amplification testing) but it is the test of choice if report time is quick. You can test by placing the order on USMLE.ORG and see how long NAAT takes to come back. I will try and let you know. But this is gold standard. Others not much recommended - antigen test needs urethral or cervical swab, invasive -- you may order but it is good to know NAAT is test of choice now.
HIV - 4th gen ELISA test of choice - quick report time, good sensitivity and specific... like that.
Knowing the differences between some recommended tests also help you with MCQs.

2. Which case did you see where they are ordered at same time....? If you saw that in pneumonia case or UTI case where the source is apparent, it is fine to use the order screen to order at same time. Blood cx draw time is immediate so it is like you are order culture but are also ordering antibiotic so sequenced fine... but definitely not order antibiotic, ADVANCE clock and then culture in which case sequence will be incorrect. OSince window to give antibiotics is within 1 hour of SIMULATED time, there is no rush to give abx before drawing cultures. In ********** cases that I saw, cultures are ordered before antibiotics and clock is advanced a few minutes before antibiotics are entered. This is what Archer refers to as "sequencing correctly." Archer says that in cases like Sepsis and Infective endocarditis - where cultures determine the diagnosis, selection of antibiotics and duration of treatment, it is very important to sequence those correctly and it is SCORED on the exam.

3. From the office, direct admits to ward are allowed to the hospital if vitals are stable, pt with no other condition that needs immediate assessment, and patient is not in severe pain. If vitals unstable, severe pain, or supected stroke/ MI/TIA/ gross GI bleeding that needs immediate assessment, must go through ER so determination can be made whether patient can be admitted to Ward or ICU.

 

[pip-tazo]

@gjones33,
1. Selecting a test depends on its sensitivity, specificity, timing and invasiveness. Guidelines differ. In PID, you can get certain tests but in disseminated gonococcal the yield is quick and good with different type of tests from other sites like oropharynx.
Most often it may not matter on CCS software but keep any eye on report times. You want to order a test with quickest report time and yet sensitive so you can get some diagnosis and manage the case.
As you know, cultures take a long time. I did not check how long it takes for NAAT ( Nucleic acid amplification testing) but it is the test of choice if report time is quick. You can test by placing the order on USMLE.ORG and see how long NAAT takes to come back. I will try and let you know. But this is gold standard. Others not much recommended - antigen test needs urethral or cervical swab, invasive -- you may order but it is good to know NAAT is test of choice now.
HIV - 4th gen ELISA test of choice - quick report time, good sensitivity and specific... like that.
Knowing the differences between some recommended tests also help you with MCQs.

2. Which case did you see where they are ordered at same time....? If you saw that in pneumonia case or UTI case where the source is apparent, it is fine to use the order screen to order at same time. Blood cx draw time is immediate so it is like you are order culture but are also ordering antibiotic so sequenced fine... but definitely not order antibiotic, ADVANCE clock and then culture in which case sequence will be incorrect. OSince window to give antibiotics is within 1 hour of SIMULATED time, there is no rush to give abx before drawing cultures. In ********** cases that I saw, cultures are ordered before antibiotics and clock is advanced a few minutes before antibiotics are entered. This is what Archer refers to as "sequencing correctly." Archer says that in cases like Sepsis and Infective endocarditis - where cultures determine the diagnosis, selection of antibiotics and duration of treatment, it is very important to sequence those correctly and it is SCORED on the exam.

3. From the office, direct admits to ward are allowed to the hospital if vitals are stable, pt with no other condition that needs immediate assessment, and patient is not in severe pain. If vitals unstable, severe pain, or supected stroke/ MI/TIA/ gross GI bleeding that needs immediate assessment, must go through ER so determination can be made whether patient can be admitted to Ward or ICU.

What is the NAAT test for chlamydia/neisseria on the NBME software for CCS? I was messing around with the practice NBME software to get familiar with it and nothing pops up when i try searching for NAAT and I used board search key words. Isn't the DNA probe urine for chlamydia/neisseria a nucleic acid hybridization test not the NAAT? Will that be sufficient enough instead of doing urethral swabs?

 

[Mahanddeem]

Hello guys, really need your help.
I am an old international graduate (15 years ago). Had my USMLE 1 and 2 and CS done in 2010, 2011 and 2012, barely passed with passing scores all first attempts. I had an IM internship year in a program for one year.
Never had taken step 3 until last December 2019. I failed with 190. At that time I took long time studying for it using mainly master the boards step 3 and Uworld Qbank. Averaged 55% correct in untimed and tutor mode. Never did the UW assessment before my first exam which was a huge mistake. My result came mid January with fail result (biostats were the only topic marked as below my score). I came back to studying for it. Went back through master the boards and had a subscription of MedReview videos. Did Kaplan this time and finished it. Reviewed the materials and few days ago had Uworld assessment 1 and scored 183. Today I had done block 1 and 2 of the second set. Scored awfully with %40 and %42 in the first and second blocks, and now got depressed and closed the whole thing. My exam in 5 days and I doubt that I will still take it. The problem is that now I can do Uworld and score in the %70s in timed random blocks but that seems not to help because I feel I have memorized the questions and answers, feeling I have "burnt" that qbank. Kaplan seems primitive and unrealistic compared to uworld (based on my real life exam experience, plus its cover for biostats is a joke). I feel myself disoriented and clueless when I was doing Uworld assessment (ofcourse new to me) questions. And was unsure of every response to every question. Wasn't surprised by the results.
Now I feel depressed and don't know what to do. What do you advice?
Thanks in advance

 

[steveme]

What is the NAAT test for chlamydia/neisseria on the NBME software for CCS? I was messing around with the practice NBME software to get familiar with it and nothing pops up when i try searching for NAAT and I used board search key words. Isn't the DNA probe urine for chlamydia/neisseria a nucleic acid hybridization test not the NAAT? Will that be sufficient enough instead of doing urethral swabs?

DNA probe is perfect. Just for MCQ so you know NAAT is preferred. I did not put in NAAT in new software so i did not know. But DNA probe is the one we always used. Please note though that if you get an MCQ, pick NAAT as preferred over DNA probe.

 

[steveme]

Hello guys, really need your help.
I am an old international graduate (15 years ago). Had my USMLE 1 and 2 and CS done in 2010, 2011 and 2012, barely passed with passing scores all first attempts. I had an IM internship year in a program for one year.
Never had taken step 3 until last December 2019. I failed with 190. At that time I took long time studying for it using mainly master the boards step 3 and Uworld Qbank. Averaged 55% correct in untimed and tutor mode. Never did the UW assessment before my first exam which was a huge mistake. My result came mid January with fail result (biostats were the only topic marked as below my score). I came back to studying for it. Went back through master the boards and had a subscription of MedReview videos. Did Kaplan this time and finished it. Reviewed the materials and few days ago had Uworld assessment 1 and scored 183. Today I had done block 1 and 2 of the second set. Scored awfully with %40 and %42 in the first and second blocks, and now got depressed and closed the whole thing. My exam in 5 days and I doubt that I will still take it. The problem is that now I can do Uworld and score in the %70s in timed random blocks but that seems not to help because I feel I have memorized the questions and answers, feeling I have "burnt" that qbank. Kaplan seems primitive and unrealistic compared to uworld (based on my real life exam experience, plus its cover for biostats is a joke). I feel myself disoriented and clueless when I was doing Uworld assessment (ofcourse new to me) questions. And was unsure of every response to every question. Wasn't surprised by the results.
Now I feel depressed and don't know what to do. What do you advice?
Thanks in advance

I am so sorry. It can be very stressful not to pass step 3. Step 3 is more a tricky prep where MCQ alone will not get you through. You need both MCQs and CCS. Also, how you perform on CCS is very important and determines your passing chances a lot just by its effect on reducing the need for you to perform too high on MCQs.

Check your score report and see if your CCS is lower than the score or same as the score. If it shows "lower" or "same", it is a "failed" performance on the CCS. Practice CCS on the official software, learn the tricks since there is not a great guidance on Uworld. I found ********** to be the most accurate with scoring strategy and since it uses official software, you exactly know how exam software responds and how to score high on each and every case.
Read everything in this thread. Do you think you have done stuff like these on the CCS? could you have missed monitoring , timing, sequencing etc?

If you score very high on CCS, you can limit how much you have to improve on MCQs. You must improve on MCQs also. You can try a theory course like archer and do kaplan notes. You need to understand what they test commonly and practice those type of Qs. UWSA score correlates poorly with exam because CCS makes that mcq-based prediction useless. You may assess via NBME although it is not accurate. Here is one well-researched article regarding NBME score range that may predict passing. See how it widely varies based on CCS : What predicts USMLE Step 3 performance?

 

[Jay2910]

Hey everyone,
I too have some questions on the CCS portion. The feedback part keeps giving like duration for when antibiotic is good for . .. but in the software it does not allow us to put it in. So should we really pay attention it?

Also how do we practice with the CRUSH Step 3 book by Movalia? it has good cases, nd explanations but I can't input anything into the software.

 

[Jay2910]

Does Acher review go over the Uworld cases and show how it is done correctly? Or does he have a different set of CCS cases all together?

 

[steveme]

Hey everyone,
I too have some questions on the CCS portion. The feedback part keeps giving like duration for when antibiotic is good for . .. but in the software it does not allow us to put it in. So should we really pay attention it?

Also how do we practice with the CRUSH Step 3 book by Movalia? it has good cases, nd explanations but I can't input anything into the software.

Hi Jay, there’s no duration on exam CCS . You go by simulated time. You advance clock and see how far it takes you and if you are meeting the criteria. On 2-min screen, you put in orders for later date for follow up at which time you could re-evaluate. You can use Archer videos for understanding key strategies and demonstrations of many cases on FRED software and practice on the FRED software ( exam software to download from usmle.org step 3 ccs materials). You can also use Uworld ccs software , it has quite a few errors that we discussed in this thread but overall, it can be useful.

 

[steveme]

Does Acher review go over the Uworld cases and show how it is done correctly? Or does he have a different set of CCS cases all together?

The one I used in the past was Intense CCS prep which had about 85 cases, these are supposed to be highyield for the exam. Exact Uworld cases are not in Archer because everyone has their copyrights. Acute MI, aortic dissection are going to be there everywhere but presentations will be different. Guidelines and approaches on Archer are the most accurate I have found among any ccs reviews. Like mentioned above and discussed in this thread, Uworld has many errors and deviations from original exam FRED software.
Good luck !

 

[steveme]

Know approaches to each of these very well, they are high yield. Some are 10-mins and some 20-mins.

A list of important CCS cases to solve:
This list is from Archer-CCS. Please feel free to add to the list if you find more high yield cases.

1. DKA
2. Pulmonary embolism
3. Endometrial carcinoma
4. 1 day old Newborn Down’s baby presenting with vomiting/ Duodenal Atresia
5. Motor vehicle accident with splenic rupture
7. TIA
8. Acute Hepatitis A
9. Secondary Hypertension, Hypokalemia – adrenal mass
10. Minimal change disease: Child had scrotal swelling.
11. Constitutional growth delay in African American kid
12. Pericarditis
13. VSD
14. Acute MI
15. Osteoporosis with compression fractures
16. Gastritis secondary to NSAIDs use
17. New Onset DM type II
18. Pregnancy
19. Anaphylactic reaction/ Shock
20. Adrenal Mass/ Hyperaldosteronism/ Hypokalemia/ Young woman presenting with leg cramps & weakness
21. Heat Stroke
22. Ovarian Teratoma
23. Inflammatory Bowel disease
24. Vaginal Bleeding secondary to Fibroids requiring hysterectomy. ( Woman 44 y/o)
25. cervical cancer26. Turners syndrome
27. UTI/Sepsis – 76 Y/o woman sent from NH for evaluation of altered mental status
28. Hepatic encephalopathy
29. Acute Cholecystitis
30. G6PD deficiency
31. Constipation, hypercalcemia, primary hyperparathyroidism
32. Pregnancy with asymptomatic bacteriuria
33. Back pain due to osteoporotic fracture – compression fracture
34. Bipolar disorder
35. Pulmonary embolism
36. Abdominal Aneurysm Rupture presenting with backpain/ No Hypotension at presentation – Vitals stable, so you can get CT scan and then surgery consult.
37. Chlamydia trachomatous (in a male)/ Non gonococcal urethritis
38. Erosive esophagitis/ GERD
39. Panic Attack
40. Acute Asthma Attack – 14 Y/O female with wheezing, Sob
41. Obesity in a teenager
42. Toxic Shock syndrome/ Tampon use
43. Hyperglycemia/ new onset DM Type
44. fracture neck of femurs – 75 y/o female fell and sustained right hip fracture – Ortho consult, ORIF, fall prevention, hip protection devices, Osteoporosis screening, DVT prophylaxis
45. HIV with pcp and lymphoma
46. child abuse with sub dural hemorrhage
47. Tylenol overdose
48. Heat Stroke
49. Acute PID
50. Tricyclic Overdose {40 y.o. Arab male with no history know brought in the ER by a neighbor with unconsciousness and unresponsive state – he had some depression as per neighbor (TCA TOXICITY)}
51. Acute pancreatitis
52. Child with intussusception
53. Woman with multiple sclerosis ( comes with weakness and has nystagmus on neuron exam)54. Septic pulmonary emboli in IVD abuser.
55. Stable Angina
56. SLE
57. Pregnancy in a 44yr old women
58. Bacterial Meningitis in an infant
59. Juvenile Rheumatoid Arthritis
60. Anemia secondary to colon cancer
61. Alzheimer’s Disease(had to rule out other causes of dementia before making the diagnosis)
62. 50 + y.o. M with epigastric pain (erosive gastritis, had h/o long term NSAID use) – Has age criteria for EGD.
63. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)
64. 4 yo. F with ANA +ve Arthritis65. 50 + y.o. F with high BP in office
66. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+
67. Acute manic disorder
68. UTI with 12 week pregnancy
69. child abuse
70. acute diarrhea
71. Acute MI
72. CHILD ABUSE : 2 y/0 AA boy was brought with lethargy, CXR revealed multiple posterior rib fractures and CT head subdural hematoma —Child abuse, call child protection services and social work consult
73.) Eclampsia… presented with seizures and peripheral edema at 38 weeks pregnancy.( Magnesium sulfate, induce delivery, if still seizure – follow status protocol)
74) Uncontrolled DM type 2 – came with increased thirst and urination
75) HIV in a 25 y/o f with multiple partners – came with weight loss, fatigue and cough. Do HIV test, viral load, genotyping. Then cd4 count.
76) Acute pericarditis.
77). Right upper quadrant pain, cxr – pneumonia – right lower lobe – community acquired pneumonia
78) Dysfunctional uterine bleeding
79) Polymyalgia rheumatica
80) Trauma patient with cardiac tamponade
81) Pancreatic ca, old man with fatigue, weight loss – exam shows icterus – go ahead with CT
82) 9mos old baby with fever unknown cause all tests including cbc are negative ( Roseolum infantum)
83) hypothyroidism in a man
84) Post menopausal bleeding in a woman not on HRT/ benign endometrial hyperplasia85) cystitis
86) septic arthritis
87)gastric carcinoma
88)incomplete abortion
89)Atrial fibrillation
90) Diverticulitis
91) Dehydration/ Hypernatremia
92. 20 month old African American boy brought for fatigue and lethargy to office/ Fe deficiency
93. Acute Bacterial Prostatitis
94. ALL in a 5 year old/ 5 yr. old boy who came with weakness, disinterest in activity and lesion on leg.
95. Acute pericarditis – rx ( make sure to do echo, don't do unnecessary pericardiocentesis if there is mild to moderate pericarditis with out clinical or echocardiographic evidence of tamponade)
96. Osteoarthritis of the Knee ( if there is large joint effusion, always do arthrocentesis)
97. CIN III
98. Congestive heart failure in a post-op patient ( make sure they are not giving too much IV fluids in post op setting, I/O monitoring, daily weights, Lasix, 2d echo, r/o MI, EKG, CXR, BNP – Lasix, if flash pulmonary edema, give morphine)
99. Hypercalcemia/ renal mass ( likely RCC) – Elderly man presenting with fatigue
100) Complete Heart Block - Woman coming with Motor Vehicle Accident/ only minor injuries on the arm , Vitals reveal Heart rate 38. - EKG shows complete Heart block