My CCS Cases

Discussion in 'Step 3' started by Guest, Oct 31, 2005.

  1. Guest

    Guest Guest

    My Step 3 Cases:

    1. 40ish woman with newly diagnosed DM II
    2. Ectopic pregnancy
    3. 60ish man with dyspnea: newly diagnosed CHF
    4. PUD
    5. 30ish woman with Colles fracture – Domestic Violence
    6. 9 month old child with FUO (all cultures negative)
    7. TCA OD with suicide note (never got better)
    8. Adolescent girl with DUB
    9. Elderly man with abdominal pain: ischemic bowel

    This was my 2nd time taking Step 3 and I hope I passed this time (I’m soooo nervous but crossing my fingers)! I have a question, I thought we were supposed to have about 27 minutes per case, but maybe because I work fast (knew how to access all the orders/buttons) or because I kept hitting “notify me with next result”, my cases all ended in about 10-15 minutes! I felt kind of worried about that. The ectopic pregnancy case ended in like 5 minutes, even though I worked her up, got the Dx, got surgical consult and prepped her for OR, and everything! I thought the cases only ended early if you do really bad or really good but I am not sure what is going on. All my pts got better (except the TCA OD) and I was able to enter a Dx for them all.

    On hindsight, some things I forgot and comments (in case you get any of these cases):

    • Ectopic Preg Case: I prepped her for surg (OB consult, coags, Foley, type & cross) but forgot the NPO order. Actually, after U Preg was +, when I did the transvag and abdominal ultrasounds, the mass was only 3x4 and so I thought she could be managed with methotrexate (since it was under 5) but when I got the OB consult, they said they were taking her to surgery!

    • CHF case: I started him on Lasix which solved his dyspnea, but I forgot to order KCl and ACE-I as well. I did remember the Echo, EKG and everything, even got a Cards consult (maybe that was overkill). He got better.

    • Duodenal Ulcer Case: this man was on long term ASA for arthritis and so I stopped ASA and changed him to celecoxib, then got a colonoscopy (since he had + FOBT and he was older) plus since he had “gnawing pain” and it got better after eating, I knew it was PUD, so I did tests for H. Pylori (all negative) I believe it was after EGD that I saw the ulcer, so I started him on omeprazole, and he got better.

    • The Colles fracture: I knew it was a DV case because she came with her husband but he was angry and wanted to leave and on her ROS she had h/o several other injuries and stuff, so I got a social work consult, gave the pt safety counseling (or is it called domestic violence counseling?, can’t remember) and got an Ortho consult (just in case, but they said I should take care of it myself) so I splinted it, not sure if that was correct and gave her NSAIDs. At first nothing happened, but then she finally admitted it was an abusive relationship and agreed to stay with friends, plus her hand got better.

    • 9 month old with FUO: I was perplexed because he had been on 2 different ABx with no effect and had a 104 fever and I did pan cultures, blood, urine, even LP and all negative (I did not get a CT before the LP but he didn’t have any signs of ICP so I hope that was ok), anyway, I tried 2 different ABx and by the 2nd one he got better so I D/C’ed him and switched it to PO form.

    • The TCA OD was a man who had written a suicide note and empty bottles were found near him, I did UDS (took so long to get results! I guess I should have done serum DS) and Acetaminohpen, BAL and ASA levels but all negative. I had to intubate him because his breathing was so poor and transfer him to ICU and even gave him naloxone but it didn’t work (I think I forgot to DC that at the end, oops) and then finally the UDS came back + for TCAs and just then his wife came in with the empty TCA bottle! I already had him on constant heart and BP monitor and maybe I should have given him something for QT prolongation but I could not remember what drug to give, so I just stabilized him and at the end before the case ended, I order Psych consult even though he was still unconscious, just so they’d know I thought of it. He never got better. Maybe I messed this one up by not treating the QT prolongation? I never did NG lavage or charcoal because he was unconscious the whole time and I had to intubate him and I was not sure if you can do all that on an unconscious pt, for fear of aspiration. I gave him IV fluids, but I cannot remember if I put a Foley on. Is there a Poison Control consult? I did not order one but just thought of it now.

    • The girl with DUB also had a h/o sexual promiscuity so I did Pap, and cultures but all were negative. I started her on NSAIDs and OCPs and she got better. I did order UPreg (-), CBC (normal) so I never did coags and all the bleeding factor tests, maybe I should have. I also made sure to give her safe sex counseling. She got better.

    • The elderly man with abdominal pain and many risk factors (h/o MI, CHF, a fib) was screaming ischemic bowel to me, so I did abdominal XR and then abdominal angiography which showed the blockage in the SMA, so I got surgical consult and prepped him for OR, and the case ended.

    Ok, hope this helps someone out there. If you have any comments on my management, please let me know. I really do hope I passed, I cannot bear the thought of taking this AGAIN, it’s so agonizing!! I guess it will all depend on how I did on the MCQs. Since I am a Psych resident, some of the questions were hard for me because I only had 3 months of Medicine floors in my residency.

    Anyway, good luck to everyone out there!
  2. Guest

    Guest Guest

    Good News!! :-D

    I got my results and I passed, 201/82. I am so relieved, it was utterly stressful taking it twice. Ugh. I wish you all luck, keep trying, I am proof that it can be done!!
  3. Guest

    Guest Guest

    What I used...

    I used Kaplan books that I borrowed from a resident in my program who took the 10 day on-site course, Q Book, NMS, Kaplan Q Bank ($150 for 3 months I think) and Crush Step 3, as well as a little of First Aid for Step 3 but I didn't have much time to use that one.

    I bought a few other books also, but didn't have time to use them extensively. Each day I'd do about 50 Q Bank or Q Book questions and carefully revise the answers, and spend about an hour revising sections of the Crush Step 3 book, I spent more time on weekends and call days. Then I took a week off work before the exam and studied about 7 hours a day and made sure to sleep well. Good Luck!
  4. Dr. Anis

    Dr. Anis Guest

    difference between splenic sequestration and splenic infarct

    difference between splenic sequestration and splenic infarction in sickle cell disease? both are caused by blocking the vessels in spleen, right? difference?

    ans :splenic sequestration is caused by intrasplenic trapping of rbcs causing a precipitous fall in hb level and potential for hypovolemic shock.

    splenic infarction is necrosis in the spleen due to interrupt of blood flow (vascular occlusion).
  5. gj

    gj Guest

    i didn't pass my first time either... advice...

    I didn't pass and am planning on taking it again in late april.... how did you restudy or whatever. I got very bogged down with the usmleworld although my scores were ok. I just didn't feel like the questions were appropriate and so now I'm hitting kaplan qbank and am going to know crush step 3. I should have probably taken everyones advice the first time. So what do you think? what helped you the most when you retook it? any advice would be great!!!

    gj
  6. Doc.8

    Doc.8 Guest

    Hi guys,

    I thank you all for the support and tremendous help through out my journey to this day. I know I could have never done it without your help.

    this was the most difficult exam. I didnot write my experience because i was not sure how I did .my lowest performance on score was on CCS although I thought all my cases went well and ended quickly. may be i didnot do a lot of things in them and just diagnosed and treated.

    I studied for thee months seriously. although i started six months ago but could not focus. I did uw twice, ck kaplan notes, step three kaplan notes and swanson. in the last month i did kaplan q bank. that was really helpful.
    on the exam i had a lot of questions that i had no idea about. there were alot of EKGs and xrays and ultrasounds. three media clips and some CT scans.questions were very loong and vague. in last blocks i was just reading answer choices and scanning the qs. i ran out of time in two blocks. there were alot of trauma qs. when i came back the first day i was thinking nobody should give it without atleast three four months of residency.

    the second day was much better. qs were abit easier. and I though i did great on CCS but teh performance in only borderline.
  7. kalamazoodoc

    kalamazoodoc Guest

    CCS cases

    Hi Doc.8..Cna you please list the CCs cases you got in the exam..? Thankyou.
  8. Linna.

    Linna. Guest

    MY STEP 3

    Got 95. NBME 350, 1 week before (I was very ill). Kaplan 75% (never repeated, did in timed fashion). UW 7 months before the exam: 68%.
    Usmle123*3 months: predicted 85-95 on the exam 1 month before the exam.
    Did MKSAP 14 (questions also), read Kaplan books for steps 2@3, Washington Manual, Secrets, Vignettes.



    I made basic mnemonics for cases and tried to use humor. Use needed when it's not dangerous (for example, furosemide in hypovolemic shock or hypokalemia)
    Common:
    1. acute condition - heart:
    ABBCCD EXEEE LLCCFSB (Lizzie from FSB)
    ABBCCD: ABG, BNP, BMP, CBC, Cardio (monitor, BP, etc.)+ or- D-dimer (if suspect PE)
    EXEEE: ECG, X-Ray (CXR, AXR - if spleen rupture is suspected), enzymes, echo, +- enalapril
    LLCCFSB: lipids, +-LFTs, +- Cath, +-centr. line, +-furosemide, +-B-blockers (if no brady, acute systolic card. failure or AR)

    2. Head
    ABCDE
    CLC (CLeopatra Cap): CT head, LP, CSF

    3. All - critical
    Additionally to ABBCDE
    BCTPFON (BaCTria PapHos No (nation)) Bactria war - Alexander the Great - greeks knew no nation above Bactria that time

    B - Bleeding time / Barium (invagination or sigmoid volvulus)
    C - CXR/ CT -abd/ +- colonosc (not in diverticulitis)/ centr. line (especially in JVD changes)
    T - titers (infectious diseases) -ELISA, etc., Toxicology
    P - Pt/Ptt
    F - fluids/ feet - elevated or down
    O - omeprazole / orthostatics
    N - NPO, NGT

    4. Obtundation

    ABBCDE +
    LUFPHECCT
    LUFtHansa is the best: airPErfeCCTioN) - no obtundation while awaiting a flight

    LUF: LFTs, U/A, Foley, fever (?)
    PHE: Pt/Pttt, enzymes (CK - all fractions, +- LDH, cardiac, +-Lipase); HCG,
    CCT: Ct - head, CK (again - do not forget b'o possible rhabdomyolysis), all toxi


    5. gynec/obst (many cases outpatient)
    PLEB R LOWGTH FDD
    PLEBs in Rome were the LOW class. They never knew GoTHic Fiction, but never DDumb. Their women had no gynecological care.

    PLEB: PAP, LH, labor, laparotomy, LOOP, Levonorgestrel, estrogen, ergotamine, evacuation (abortion), episio, endometrium care; Bleeding: stop; breast, Bishop score
    R- RPR, Rhogam, rubella
    LOW: lipids (if CAD, DM+), OCPs, osteoporosis, weight, wet mount
    GTH - glucose, thyro-, HCG. hydroxyprog. (17-KS, 17-OH)
    FDD - FSH, folic, fetus, D-dimer (if SOB in pregnant, HRT), DHEAS, DEXA

    I made also some other mnemonics for some cases.
  9. sweetsmitha

    sweetsmitha Guest

    thanks desichick, your ccs cases description is very helpful

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