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dongyang: Step3 experience with updates on CCS
作者:USMedEdu
发表时间:2014-04-21
更新时间:2014-04-21
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发信人: dongyang (dongyang), 信区: MedicalCareer
标 题: step3 experience with updates on CCS
发信站: BBS 未名空间站 (Sat Apr 19 18:06:12 2014, 美东)

Finally, finished the step3.

Preparation material: UWorldx1.5 times, MTB3 briefly, Google, wiki
Study Time: PGY1, 2 week vacation time (~8hours/day except one weekend) +2-
3 week (3-5 hours/day on no-call day, had one week NF, had hard time study),
mostly by myself, had several Skype discussion with friends for CCS.
Pre test score range: UW 50-70% Sim 227, NBME3 offline 73% (the day before
the test)

The first day is much harder than the 2nd day, I got many statistic
questions, almost 3-5 every blocks, and the question are not straightforward
, you have to really know the concept to get it right, unfortunately,
Statistics is one of my weakness. Also, there are quite some dermatology
questions, usually with a simple nonspecific history, then one picture,
almost impossible to figure out from the question directly, so better to
google the pictures when you encounter the dermatology questions. There are
some questions testing very basic concept, like Step1, it gives you a case,
you diagnose the disease, but it’s asking you what the pathophysiology is,
so take a look step1 FA if you have time, especially all the genetic
inherent disease.

Time management: Questions are in general medium size, but there are some
quite long ones, I have to scroll down to see all. The time is very very
tight, I usually able to have 10-15min left from the UW and NBME, but in the
real test, I still have 2 questions not done when the 5 minutes warning
popped out in 3 blocks, which made me nervous. Another lesson from me is
that don’t marked too many questions and hope to take 2nd look. Only mark
the questions that you really want, you probably won’t have enough time to
review if you mark too many.

Day2, the questions are much shorter and easier, although the last block got
little harder and longer than the first 3. I will say the length and
difficulty are similar to NBME3.

Ccs part is fun, enough time for most of the cases. I took a break after the
first 4 case, then I used up all my break time before returning back to the
seat, as I know I will have extra time there. Cases are pretty classic, 1
pediatric, 2 OB/GYN, no surgery, others are IM. One of 20min case ended at
6min!

It’s definitely easier for resident to do the test, as there are some ethic
questions I probably wouldn’t know before residency. And it’s doable to
finish the test in 2-4 weeks if you can squeeze 6-10hours/day.
UWorld is good material to study, but make sure you understand the concept
inside and know the incorrect answers as well; I get couple easy questions
wrong just because I didn’t pay attention to that.

Finger crossed! Best wishes to all step3ers.

How to manage CCS is on floor 6.


How to manage step3 CCS?

It’s hard in the beginning, kind of clueless for me. But you will be able
to get the idea pretty quickly after 5-6 cases in computer. Here’s my
thoughts how to manage it quickly and try not to miss things.

1. Differential if need urgent care.
All Chest pain, SOB, AMS, post-trauma, little infant all need to be ordered
with ER order before physical exam.
ER order mnemonic will be POC IV, ( have to poke someone for IV line)
Pulse oxygen
Oxygen
Cardiac monitor and BP monitor
IV access

Then if post-trauma: Cervical immobilization.
Chest pain: EKG
AMS: Accucheck, NPO, bedrest, head elevation.
Advance to see the SpO2, if low, ABG stat, possible need for intubation.

2. Now Physical exam, always do focus first, you can always do the left
over when you are waiting for results or response. Cardio/Lung/Abd are must
have.

3. Think of differential, order tests: U PIC BF (you pick boyfriend)
Urine: UA, urine tox
Pre-OP panel: PT/INR, PTT, T&S.
Imaging: CXR, Xray of joints, US, CT, MRI
Culture: blood, sputum, urine, wound, CSF
Blood: CBC/BMP/LFT, amylase/lipase, LDH, D-dimer depending on the case
Fluid: joint- synovial fluid, CSF, pleural, pericardial, etc

4. Treatment: what’s the treatment you need to give? Of course depending
on the presentation and findings.
The rule of thumb is “any critical care to stable the patient?” like
bronchodilator, ASA+Nitro for ACS, tPA for stroke, Heparin for thrombus,
Nitroprusside for HTN urgency. This is the most important part they want to
test on.
“treat symptom”: pain- morphine, nausea/vomit- Zofran, fever- Tylenol, etc

5. Time management: To me, this is the hardest part, you have to
consider how long the patient may need before showing response while you don
’t want move too fast to miss something. Office cases are easy, order
things, then send home and you should have all the results before next
appointment.
For ER cases, if real time allows, go slowly, advance to next available
result. Or q30min, 2 hr depending on pt’s condition. You can order vitals
as qx times, then advance to next result, so you will see all the updates.
Make sure to order interval history and focus PE or complete PE if you haven
’t done one between, which will also advance the time.

6. Counseling: SAME DOC. Fit almost everyone.
Smoking
Alcohol
Medications: side effect, adherence, etc
Exercise
Diet: low Na, low fat
Others: relaxation, sex
Car: seat belt

7. Stop: when patient improves, don’t forget to stop things, like NPO,
bedrest, and change IV to PO if possible.
And order screening test if pt not done yet, like pap smear, mammogram,
colonoscopy.

8. Good habit: when you practice, form a good habit; write down the
important information on the paper like age/sex/Chief complain/duration/
associated symptom/important PMH/social hx (for SAME counsel)/abnormal tests
/any thought during the review process. Thus you won’t miss anything.

Good luck, all step3ers!

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