Discussion in 'Step 3' started by Guest, Nov 7, 2004.

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    USMLE Step 3 CCS

    Recent CCS :

    1. A 30 year old female patient with a cold and infraorbital headache --maxillary sinusitis.
    2. A Latino 30 yr old pharmacist with low grade fever and PPD test positive -- treatment of tuberculosis.
    3. A Latino male who is s/p colon carc resection and admitted to hosp. for treatment of pneumonia developed chest pain - pul.edema/chf.
    4. A Latino alcoholic female who is pale and tired; cbc shows hyperseg. neutrophils and increased MCV--folic acid deficiency anemia.
    5. A Latino 12 month old child with high fever (40 C) --blood culture showed gram positive coocci in pairs(work up of sepsis)
    6.A 25 year old female with H/o DM Type I came to er with n/v loss of appetite ---DKA with urinary tract infection ( as UA showed positive nitrites and leukocytes)
    7. A young female with burning urination and foul smelling vag discharge--Trich vaginitis.
    8. A 60 year old female with headaches and stiffness of joints----Polymyalgia rheumatica.

    1.erosive gastritis
    2.cholilithiasis in a sickle cell pt
    4.uti in a pregnant
    5.military recruit
    6.idiopathic thrombocytopenic purpura
    7.right lower lobe pneumonia
    8.pulmonary emboli
    9.iron deficiency anaemia in 18 month old b

    ... First wk of march

    CCS 1)… a 13 yo female came to office with mother with c/o increase amount fo bleeding and weakness. . Period are heavy from last two time. C/o back pain and taking some NSAID. Feeling week and some pale.
    H/o of father bleed excessively in past during dental extraction. Two brothers are ok.
    My provisional Dig was VONWILLEBRAD DISEASE.
    I will briefly tell what I did and where I found problem with soft wear of CCS.
    1) CBC, Preg teat, ua, sma7. pt, ptt
    2) result shows anemia Hb 8, pt normal ptt slightly elevated and preg neg.PLT ok. I ordered BT , factor vllI, Xi, von willibrad factor, transfer to hospital. Repeat Cbc in 2 hours . IVF, type and cross
    3) BT was 17, I started DDAVP cryopreccitate, transfuse one RBPC.
    4) Pt ok in in next 6-8 hors bleeding reduced and feeling better.
    5) could not DC pt but advised general counseling age appropriate and counseling to brothers, watch for bleeding in future, avoid ASP. etc

    CCS 2 )a 45 yo male. MVA. No seat belt, steering broken, no loss of consciousness pt breathing ok, pain on chest bruised, conscious.
    My initial impressions was Cardiac temponade or Aortic rupture.

    1) Did ABC, IVF, oxygen, cervical spine precautions,
    2) cbs,EKG, , sma7, pt , ptt, blood alchol level, xary chest, aary extremites, spine, abd xray et, VS, m onitoring. Pain killer
    3) chest xray sternal fracture, all ok, pt some SOB and distress,
    4) Ct chest, called ortho,
    %0 orths said no intervention needed, Ct showed fluid in pericardial space
    5) stat pericardiocentesis, admit to ICU, monitoring,
    6) pt got better. Next day much better
    Again time is very short in CCS , I could not do repeat CT or DC pt . B/c when we orders so many thing its take time to see result and by the time case end.
    7) Did some counseling, seat belt, age related and etc

    CCS 3 ) 7 yo Black kid with arm pain, chest pain, fever, mild distress ( office )

    pt know case of sicke cell disease and on prophylactic penicillin and had pnumo vacine.
    1) cbc, sma7, ua, chest xray , ul abdomen, LFTs, bilirubin, ivf, oxygen, meperidine.
    i did not order peripheral smear or Hb electrophoresis as knowing that its known case of SSD and we are going to see sickle cell.

    2) Hb 7, last was 8.Transfer to hospital with continue oxygen , meperidine iv, cefatriaoxne , IVF
    # pt better next day. Dc iv meperidine, started PO ,
    3) advised Hydroxyurea and hydration. )-
    Again it’s hard to keep track with time of soft wear and to understand when to dc drug or dc patient.
    4) did some counseling with drug adherence, hydration Dc cefatrione and stated PO, was already on PNC and vaccine.

    CCS 4)A 35 you hispanice female, s/p repair of femur fracture, next day nurse said

    UOP 80 cc in last 8 hours. Pt ok but c/o some pian.
    Other exam ok. pT IS ON SOME CEPHALOSPORIN( PROBABLY CFOREXIME AND SOME PAON KILLER which was not apparent NSAID, was like phenylpyrazone ?? ot Meperidine ( dont remember exactly).

    1) did initial labs, Urine cretainne, urine essinophil, urine sodium ( did not do FeNa) .
    2) there was granular cast an dno leukocyte, so I ruled out interstitila nephrits and urine NA was 45.BUN 28 and cret 4.5
    I was sure its renal Failyre due ti internsic problem and culprit is eigther cefalo or pain killer. Iwas not sure pain kille ris NASAID or not so i d/c cephalosorin.
    I am not sure I idi right or wring. I checked and idi not see cehlao cause ATN, they cause nepfrits.
    3) continue with Frusemide and fliud and some basic counseling
    Tried to counsel to avoid nephrotoxic but could not.
    Final diagnosis I made ATN and Renal failure.

    CCS5)57 yo WM c/o mild cough , no other symptoms,no weight loss, h/o smoking but quit 3 years back, mild fever.
    Chest exam with decrease BR on left base
    My initial impression was b/w CAP or cancer
    1) stared with simple test CBC, sputum gram stain. ua, chest x-ray .eat,
    CBC with wbc high, net, chest xray with lft lower consolidation and sputum with big amount of fram pos cocci.
    I treat with Azithromycn, cough syryp and f/u in one week . also orders sputum c/s
    2) did not get well in 10 week , c/o some blood in sputum. . Did Ct chest anf found mass at l lung.
    3) request bronchoscope , consult oncologist and
    diagnose os Post obstructive Pneumonia and Lung cancer.
    By bnthe time case finished.

    CCS6 ) A 72 yo with mild progressive SOB, hx of HTN and MI , on enalapril , office, PND and otherwise ok.
    On exm am some b/l pitting edema and no JVP or other s/s of acute heart Failure or Pulk edem a.

    My prov diaganois was Con hear failure sec to HTN or IHD
    1) CBC, Sma7. cxr, ekg , echocard, lipid.etc as an out patiet.
    2) results showed hyertrophy, axis dev, akinasia , EF was not given in report.
    3)staresd on next vist in 3 days, HCTZ and Digoxi, coucseeling few things , low sad, ,ow choles, exercise, complaince with drug and f/u in 2weeks.
    4) pt was better, I chked sma 7. ( I did mistakes and forgot to see Dig level but there was no /s/ of tyoxixity) pt was better.
    4) f/u in 4w, and 3 monts pt better.
    Final Diag CHF ( I did not add B blocker b/c was not sure about EF and he was already on ACE inhibitor. For got to add ASA too.

    CCS7 ) a 45 yo IV drug abuser, fever, SOB, track marks
    My initil impressin was Acute bac endocarditis ( like every one wil do)
    1.ivf, oxygen, orders initial test , Bloob c/s, cxr, cbs, urine tox, hep pannel , VDRL, etc
    2) started on iv nafficilln and genata.
    3) admitted to ICU ( I don’t know floor was better, let me know)/with cardian monitoring.
    4) did not get temp down next day. Cont AB and send another set of Blood c/s. consent for HIV test. orders Echo, showed, vegetation on TV.
    again its very hard to keep track of pt and what test to order here. its theoretically looks easy but soft wear is strange. May I did not do much practice, but I did practice. I could not see result of V Blood c/s in one week. Time was running.
    So I changes AB to Vanco and Genta b/a pt was still having fever.
    5) did some counseling, safe sex, druge ete etc, HIv test idi not came bacj but hep and vdrl was negetaive.

    My Final Giag wae Av cute Bacerila Endocraditis, I did two important step like blood c/s and start AB before result which are life saving. I did know this is what USMLE want to see or to manage case entirely which was difficult for me.
    4) in one week pt temp same

    CCS8) 35 yo legal assistance female with non bloody diarrhea
    weakness and pain in RLQ,
    My initial impression was, CROHNS disease
    1) did usual lab after IVF. LFT, CBS, PT, stool ova nd parasite, c/s, sma7.iron study, b12, FA
    2) bi2 was low, iron very low anemic, mass on RLQ, abd series ok.
    3) did barium ( upper GI) some time we can do colconscopy or sigmiod, I choosed to do Barium
    , admit to ward, NPO, TPN, B12, Iron,
    4) barium neg , did colon scope showed ileum with cobble stone pattern no mucosa infalmed.
    5) stated Masamine and predinisone and all nutritional aids.
    6) counseling few things, high fiber diet. and drug compliance and education.
    could not f/u or DC . It was chronic problem , to DC pt and f/u . B/c management takes time and every case finished in1-=20 minutes or earlier
    Finla Diag was Crohns disase
    I mean I could not see how pt did and long term follow up . How much it is imporant in CCS. ??

    CCS9) 45 yo female with discharge/ itching came to office other wise healthy

    healthy and lst pap smear was 15 months back and normal
    My initial Impression was Bacterila vaginosis
    1) did preg test, ua, koh preo, wet mount smear, CBC
    2) showed no huphes ar trichomonoas and lot of clue celle
    3) treated with Meteo gel
    4) Pt was happy in next 10 days.
    5) Schedulled Pap smear and mamogram in next mont ( to get rid of infaction.
    General couselling.

    another Set of recent CCS cases ( 2nd wk of march )

    Iron def anaemia
    General check up of a boy with HTN.& obesity.
    pulm embolism in colon ca pt
    In real exam ccs cases r really slow,,it takes its own sweat time ,,so practice well so that u dont spend time thinking there

    ccs case.


    there was also a question set on Gulf war syndrome 4 qustions, mostly how would u responde to his qustions

    1. was in the hopital treated for pneumonia 71 yr old...sob

    2. 42 yr old female with the breast mass surgeon wants to do surgery send to PMD for other medical disease. she had an upper respiratoy infection deve;lop some purpura...........came to u with nose bleed.......... her platelet was low but her BT wa 20......


    4. Obese 16 yr old came for military recuritment
    5.Bacteriuria in a pregnant 6 wk
    6. 18 month old with loss of apetite........shows anemia
    7. Sickle cell with intermitent abdominal pain

    8.vaginal discharge

    9. 70 yaer old with abdominal pain .......obstruction series shows rt lower quadrant pneumoNIA

    1. colon cancer
    3.1 child with anemia which I could not get the exact diagnosis.
    5.pulmonary embolism in a cancer patient.
    6.sedative poisoning
    8 obesity

    young woman-ac asthma,gets better with Iv steroids and albuterol
    2-kid with icterus,g6PD def
    3-woman with no complaint except fatigue-post infectious thyroiditis(T4 high,TSH normal)propranolol took care of the symptoms
    4-male middle aged-tired(like us all)we can have the luxary of saying we are depressed,he was,give SSRI
    5-overweight female(slightly)...routine visit,tired pees a lot at night,only in the US they dont think its BM..give oral hypoglycemic she wont get up at night to flush
    6-trip to Australia..leg swolllen.I wanted a picture post card but there was this little problem of PE sent her into cyber space with elevated bleeding count..last i heard of her she was doing well.I will do well too if you pay me a trip to Australia.
    warfarin etc after usual ultrasound(the darned leg is swollen) and PQ to tell higher-souls that you know it exists...CCS have nothing-well only a little- to do with what we do in real life(exam wise){p<.ooo5)

    1-Acute cholicystitis
    3-UGI Bleeding
    5-Bacterial Vaginosis
    6-Hypothyroidism + Iron deficiency anemia
    7-Alcohol Abuse
    9-foriegn body aspiration(peanut)

    newly Dxed DM type-II,
    50yo F regulur physical.
    duodunal ulcer

    1- polycystic kidney disease: 50 y.o.w.m with PMH of HTN presented with mental problem (I dont remmber). I did UA, sma7 and then Echo which was diagnostic. hemodialysis..
    2- angioderma: shellfish with edema in face and lips and SOB. epineph and o2...discharge.
    3- pneumonia (60 y.o.w with right upper abdominal pain had URI three days ago): CXR and erythromycin only!!!!
    4acute diverticulitis (50 y.o.AA.w. with left lower abdominal pain, no Occult blood), exam abdomen and rectum only!, showed mass, KUB: dilated loops. metro and cefotaxim and sendf home on diet.
    5- chf with sob, R/O MI and supportive care and add HCTZ for his regimen which included aspirin and ACEI.
    6-dmII (tricky). prostate problem in a 60 y.o.m presented with thirst and improved urinary problems.. glucose only...350.. workup diet and other junk staff and send home and F/U...The only thing happen in this case that he was still thirsty which i called him in and hydrate him..and then all massges were ok.
    7- sickle cell anemia with chest pain. supportive ICU and hydroxyurea.
    8- HTN, stage I: AA boy wants to be involved in football teem HTN repeat and repeat....then diet, smoke alcohol, drugs.... improves over 3 months...and happy!!!!
    9- pid classic easy.

    CooL's CCS cases from Past year ...

    1)ectopic pregnancy
    2)perforated PUD
    3)Anginal pain
    4)Fe deficiency anaemia in pregnancy
    5)Vaginal discharge,culture negative
    6)known NIDDM with c/o lethargy,leg pain?
    9)postmenauposal female c/o of hot flashes
    10)Tension pneumothorax

    1. 55 yr old black woman with fatigue, weight gain, loss of lat third of eyebrow, obese and other nonspecific signs/sy presented to office (got a sense of hypothyroidism)--------did cbc, tsh(don't jump right away to whole thyroid function test as tsh is cost effective compared to whole thyroid pannel....if tsh comes abnormal then do whole thyroid pannekl), comprehensive met pannel,ua and ana...tsh was high so ordered whole thyroid pannel which comfirmed started on levothyroxine and scheduled wk f/u i also ordered ekg (h/o obesity and slight elevated bp) then i struggleed about ordering about cxr but didn't instead preferred to order lipid profile(i was very ambivalent about ordering lipid profile in this guy from cost effectiveness/expense/unncessary vs necessary test etc) but surprisingly this guy had bad lipid profile so advised him low cholesterol,low fat, and low na(highbp) diet, exercise pgm, etc.....i also did stool guiac as part of yearly exam in this old pt but it was ended on time and when 5min left screening warning came, i ordered repeat tsh (to make sure,it is going down)

    2. 60 yr old african american pt with h/o arthritis and s/p chronic aspirin therapy presented to office with c/o fatigue(firsth thing came in mind was peptic ulcer dz vs gastritits)..........ordered cbcd, lyte plus, tsh,ua.......normocytic normocho anemia with slightly low h/h........did upper barium study came was feeling still same.........started on famotidine and advised to stop aspirin.......ordered couple days f/up and ordered gasstroenterology consult......still no improvement......then finally did endoscopy......and result was positive for erosive gastritis.......i continued famotidine(she was taking antacid with marginal relief), advised to quiet aspirin, quiet smoking, quiet alcohol, started her on acetaminophen for pain and case ended...........( also advise this pt about routine self breast exam, exercise pgm, mamography, advanced directive etc......Keep these age appropriate counselling in mind for every case ... cash extra few positive points.......always give pt opportunity to discuss about advanced directive....i this is new medicare and medicaid requirement and it is a law that hospital/clinic discuss advanced directive issue with all pt irrespecitve of their age)

    3. 18 months infant presented with wheezing/coughing for six hours (knew right away foreign body apiration).....started o2, iv access, cbcd, bl culture, lyptes, pulse ox, abg.....ordered cxr portable.....ordered pulmonology consult(u can ordered either pulmonology or cardiothoracic surgery consult for bronchoscopy)......message reads continue managing additional comments.........ordered felt better.......transferred to ward.......ordered clindamycin first iv and then oral therapy(for postob pneumonia) got better..message read peanut was revealed in ended on time.....(i forgot to order postbronchoscopy material for c/s as per std textbook instead started clindamycin empirically)

    465 yr old man with unilateral headache/tenderness.......classic case of temporal arteritis......ordered cbc, tsh, esr, lyte plus......esr was 100.....started on prednisone......ordered f/u appt and gave age appropriate ended

    5.yound woman brought in unconscious with bradycardia, hypotensive and pinpoint pupils classic case of narcotic od.......ordered oxygen, iv access and gave triple combo (thiamine, dextrose 50% and naloxone-all are iv bolus one time dose) got awake.(Don't go first for physical exam in this case. Unconsciousness/unstable pt warrants urgent treatment).....i then did brief physical of 3min......meanwhile i started her on normal saline, did cbcd, lyte plus, ekg 12 lead, cxr portable, pulseox, ekg monitoring, ua, urine drug scrren, blood alcohol, blood aspirin and bl acetaminophen level, ordered gastric lavage(which revealed pills fragments).......started naloxone drip.....transferred to one time i have to start here ng tube and intubation...........she eventually got better......transferred her then to ward...........ordered psy consult, advice for relaxation techquine to ease with stress ........(now can u belive what big mistake i did.....i had overdose protocol in my mind and i was writing all orders as it popped out of my mind......there i ordered charcol along with gastric lavage...this was big blunder........but surprisingly pt got better......i imagine i have her already on intubation.....even with this big mistake CASE ended peacefully)

    6 young girl with fever, headache and generalized maculopapular rash of one day onset..........classical case of toxic shock syndrome......ordered symptomatic rx...admitted and ordered cbcd, urine pregnancy, gono/chly vag culture, bl culture, cbcd, comp met pannel, ua ....started her on iv oxacillin and then oral got better (now in physical, it read "tempon removed")..........still i go ahead and wrote remove tempon(computer has this order in storage)......did contraception, drug, alcohol, smoking, safety counselling being teenager. In the case i was confused about one thing i.e. culture and sensitivity.....i was not sure where to take specimen from? so i ordered bl culture, vaginal stapyloccoal culture, and then tempon c/s (someone can help with this issue) ended appropriately

    7. 55 yr old immigrant psychiatrist came in with classical sy of pul tb------hemoptysis, wt loss, night did cbcd, ppd, cmp, ua, sputum afb smear, tb culture and pcr test.......(afb was negative.....pcr came positive after couple days) was in office.......i wanted to order resp isolation but computer won't accept it and same token case was not appropriate for admission as she was young and independent and relatively i wanted to do sputumx3 (practical and theoritical approach) but computer won't accept it 2nd time).....ppd was 12mm, cxr revealed upper apical infilt/cavity........started her on inh, pyridoxin, rifampin, etham....ordered f/u appt with f/u sputum study.......orderd inf/pneum vaccine, multivitamin/notify health dept........i also did hiv counselling in this pt.........other things to check......hep b surface antigen........( lady was not drug addcit so i didn't do rpr)

    8 one case was 50 yr old guy with symptoms of dka, abdominal pain......treated as dka but case kept dragging on and on........

    9. s/p mva, s/p internal fix of tibia # in 50 yr old guy in inpt setting.......nurse runs with c/o decreased urine of acute renal failure..........treated this case as mva.....don's assume that this pt has everything on place......start with abc....o2, iv ring lac, foley cath, spine, cxr, pelvi xray...........orderd abg, ua, lyte plus.......significantly low calcium, and k was 7.5.........ordered calcium chloride, ekg 12 lead and cont ended exactly at 14min.....diagnosis.........arf/hperkalemia/hypocalcemia......

    impt points:
    1. first always decide pt is stable or unstable.....if unstable/unconscious start treatment first and then do physical..........
    2. it takes 2-3 min to load pt.........i was scared becasue in all my pts, it was either 3rd or 4th min when i was able to wirte first order.......i think one has to be patience as computer takes little while to load info
    3. always do age app counselling....
    4. think twice before u write any order......think about cost/necessity/futility/whether it will change your mx (like always go first with tsh and then order whole pannel......first do nonfasting cholesterol before going to fasting sample)

    Do practice,practice and practice...... i have reviewed all ccs cases within last 4months from this site and practiced those couple really helped me lot in the exam......Best thing would be discuss with friend. In my case, me and my friend used to discuss everyday 5 case on the phone. while talking to eachother through cell phone, we kept our computer open and practiced on those 5 std cases. we pretended case of asthma instead of pneumothorax and wrote all ordereds/treatment of astham and watched the capability of computer and how it comes up with words........say for example while doing osteoporosis case before the test, when I ordered DEXA scan, computer doesn't recognize it but after several attempts, i was able to come up with right word"bone absorbtiometry" and computer picked up it right away so if u know this thing it will save time in real test.....thaks....

    Recent CCS cases-Mid June

    1) (messed up this one!) Female in Ward after surgery(joint). On pneumatic compressions for DVT proph. and LMWH. Has IV at high flow rate(overloaded). Complains of SOB. I thought fluid overload? CCF? Renal failure? PE. Did not get any results back. Case ended. I diagnosed her as CCF!
    2) Female in 60's brought to ER. Found unconcious by neighbor. Neighbor said she was depressed lately.I did everything...ABC's, IV, Glucose, Thiamine, Narcan, Toxicology screen, Stomach wash. Everything negative. ILast minute I ordered CT head. It showed SAH. Called neuro, Nimodipine etc.
    3)Child in office, pale, smear-basophilic stippling. Lead poisoning-Rx. Succiner. Got better!
    4)Elderly genleman in office with weight loss, tiredness, hemoccult positive. CT of abdomen with biopsy-Adenocarcinoma of Colon!
    5)Elderly female with similar complaint as gentleman above. However her cT was N. EGD-Showed metaplasia of some sort. H. pylori negative...I thought Barett's esophagus. I started her on Ranitidine?!
    6)Child, 6 hr, on Ward, Down's Syndrome, vomiting. Duodenal Atresia. Got better with NG tube!! Consult!
    7)16 yr old girl with PV bleeding. Father has some bleeding problems. All her labs except Hb. were N. I was thinking of VWD! Could not come to diagnosis-I rx. her as DUB?
    8)Straightfoward case of female with ITP. Better on Prednisolone!
    9)Pt with clinical picture of pericardial effusion. Pericardiocetesis-negative. ECHO-Dilated cardiomyopathy!

    Hope this helps!

    Another CCS posted February 15 2003

    1) young female with lower abdominal pain , usg showed a ovarian cyst , consulted gynac : said will schedule surgery continue medical management .
    it was torsion ovarian cyst .

    2) child 6 yrs old african american comes with pain in right upper quadrant and epigastric aregion and cough : rt lower lobe pneumonia on chest xray .

    3) appendicitis : rt lower quadrant pain

    4) DKA in a 17 year old girl who presented with UTI symptoms . if you guys remember some body had this case and it was posted here .

    5) acute bacterial prostatitis :
    trucker male with low back pain and perinael pain and discomfort . asked for prostatic massage and culture of secretion : came positive for ecoli . treat bactrim .

    6) alcoholic trauma patient with dizziness and abdominal left upper quadrant discoomfort rib frature : diagnosis : splenic hematoma

    7) young female with vaginal discharge : acute PID

    53 year old female with pain in abd : sigmoid diverticulitis with abcess around the sigmoid .

    9) pulmonary embolism with ccf : elderly hypertensive male with shortness of breath and history of long airtravel

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