Step 3 experience:

Discussion in 'Step 3' started by DLC, Sep 11, 2004.

  1. DLC

    DLC Guest

    Step 3 experience:
    Hello all. , here is my two pennies worth experience, regarding Step 3, CCS in particular. Hope they help some of you:

    -If you are travelling across timezones, arrive at your exam city two days prior to adjust. It is a long and tough exam, requiring max concentration.

    Day 1 is tougher, I feel. There are seven one hour blocks of MCQs. On either day, you have 1min 15 secs per question, and you'll need it because the questions are long.

    -Because of the above, ALWAYS READ THE ANSWERS FIRST!
    This will focus what you are looking for when scanning the question. For example, the actual choices may be about what ethical decision to make, but the body of the question will contain lots of technical waffle.

    -Focus your studies on satellite/office settings. This is the bulk of the exam. In fact, those of you with family practice experience will love Step 3.

    Day 2 includes ~3 shorter blocks of questions, followed by CCS.
    Now on to CCS which is what this posting is mainly about:

    -The CCS is really good fun to do actually! Very enjoyable.
    The cases (nine in all) are usually quite easy to diagnose. The issue is how to manage them appropriately.

    -Before doing the actual exam, you MUST play around with the five sample scenarios that you are given by USMLE. You should also do practice scenarios and think yourself through the case.

    -When you start, you are given a one sentence introduction, like: "a 45 year old white man attends complaining of severe chest pain."

    Next, you will be shown the History of the Presenting Complaint, plus PMH, DH, Allergies, FH, ROS, etc.
    Up to this point, you have no options, you just have to read through and note the key points.

    Before you leave this page, you should do the following:
    -Decide on a NARROW differential diagnosis (yes, even before any physical exam has been done).
    -Make note of allergies, so you don't accidentally administer the wrong Rx.
    -Make note of risk factors like smoking, obesity, hyptn, etc., and at the end of the case, you will win points by COUNSELLING your patient about these. [in the Order page, you can type 'counsel' and click, which will show you all the choices of things to counsel on]
    If pertinent, you can also end your case by ordering sensible screening tests, like mammography, pap smear, etc

    Okay, now that you have read the full history and decided on a narrow differential, you must next answer this very important question:

    Is the patient stable?
    ie. will I need to do anything right now?

    If yes, do not waste time proceeding to the physical exam, this is inappropriate. Imagine yourself physically there. If you had a man with severe chest pain before you, would you do a thorough exam first? No. You'd immediately bang on some oxygen, pulsox, iv access (for pain relief, among other things), EKG and portable CXR. Don't forget ABCs, ever.
    And if indicated, do not forget obvious tests like: ABG, PEFR, serum glucose, urinalysis!
    They are so routine that you might forget about them.

    And another important point, what if this happened in an 'office'? You could get away with applying oxygen and perhaps an iv line/analgesia (if the simulator lets you), but you must very soon 'move location' to ER, where you can carry out further management.

    If your patient is quite unwell, you will be justified to do lots of emergent things before the actual physical exam. Once you have done those, move on to the PE and click which systems you want examined. A cardio/resp/abdo exam should always be in there, I think, .. plus any other relevant ones.

    Once you have read the PE findings, you will be able to narrow your differential even more. And, for example, once the CXR & EKG & blood results come back, you will have a primary diagnosis.

    This will be the time to start specific management.

    If you have ordered a number of tests and are waiting, you can move the clock forward to get those test results.

    If your management is working, you will get feedback like 'the
    patient appears less breathless' or 'more comfortable'.

    If you've gotten the diagnosis & therefore the management wrong, you may see feedback like 'the patient is getting more breathless', etc.

    Remember the location! If your patient is quite unstable, eg. acute heart failure, MI, DKA, pneumothorax, MOVE THEM TO THE ICU. (In the USA, generally DKAs and pneumothoraces are cared for in ICU). If necessary, give them a central line, or PA catheter, or arterial line. If immobile, remember heparin.

    If you see a well patient in an office, with a minor complaint, there is no need to rush. You have time to examine them. Then order any tests if necessary. If you need those test results to get your diagnosis, don't leave the patient hanging around in your office all day and all night!

    Every test you order will show you what time/day it will be back. In an office, most blood tests take about a day. So, send the patient home (with analgesia or whatever else needed) and give them an appointment to come back when the test results are ready.

    Particularly in an office setting, you may need to see your patient two or more times over a few weeks, to make sure they are getting better. So, for example, if you see someone with Fe deficiency anemia, don't just give them some ferrous sulphate and counselling, and not see them again!
    And always remember to counsel them as required, eg. drug compliance, smoking cessation.

    Altering patient location also applies in the reverse. If your patient on ICU is much better.. send them to a normal ward.

    Remember that you will not benefit from overtreating. If you
    do an invasive or expensive procedure when not warranted, you risk losing points.

    You are expected to be the primary physician to the patient.
    But in general, you will not be able to carry out specialised things like evacuating a subdural hematoma. So, if you need to order a specialised procedure, you will need to involve the relevant specialist.

    By typing 'consult' in the orders page and clicking, you will get a choice of specialists.

    BEFORE you refer to a specialist, you must have enough evidence of your reason for referral, otherwise they won't come. I'll clarify, if you see a patient with a cough, the pulmonary meds will most likely decline your referral. But if you perform imaging on the chest that shows a discrete lesion,
    not only will you interest the pulmonologist, but perhaps also the oncologist. So my point is, you must have solid evidence for a referral, eg. by imaging.

    Once you refer, you may find that they go ahead and operate on the problem.

    Okay, I guess that's enough for now. I'll add further comments later. All the best!

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