The ULTIMATE GUIDE to CCS Cases | How to ACE the STEP 3 CCS Cases

Key points: 1. Timing (1:01) Real time = the actual time/real world time, which is 10-20 min. Simulated time = hypothetical time, which can last from hours to days to weeks. 2. What to look for in case's introduction (2:18) Age Gender Allergies Main HPI points Screening (vaccinations, pap smear, colonoscopy, etc) 3. Physical exam (3:45) Complete physical exam --> if patient is stable or in the office Focused physical exam --> if patient is unstable or in the ED; you can always do a complete PE later in the case after putting in emergency orders! 4. Disposition (4:35) Where do you want the patient to be? Options: home, ED, admit to inpatient, admit to ICU. 5. Emergency orders (5:55) MAVOCCF, which stands for: Morphine Acc (gives you IV access and glucose accucheck) Vitals check Oxygen/oximeter Cardiac monitor C-spine Fluids (normal saline) 6. Routine orders (6:51) CCCMP CUAEH LLUSCENT stands for: CBC, CMP, Creatine phosphokinase, Magnesium, Phosphate Chest x-ray/other x-rays, Ultrasounds, Abg, Ecg/other cardiac tests, Hcg Lactate, Lft/pt/ptt/inr, Urinalysis/culture/toxicology, Stool culture/pH/ova/etc, Culture (blood), Esr/crp, Neuro checks, Tsh 7. You should land on a diagnosis by this point and thus, a treament (9:09) 8. Case might finish early if you have managed the patient correctly (9:27) 9. Once the case finishes, you have 2 minutes at the end to put in last minute- orders (10:00). These can be pap smears, colonoscopies, vaccinations, counseling the patient on various topics. SITPM (vaccines) CPM (screening tests) ISSSAD (counseling) Shingles Influenza Tetanus Pneumococcal Meningococcal Colonoscopy (50-75 yrs, every 10 years) Pap smear (21-65 yrs, every 3 years) Mammography (50-75 yrs, every 2 years) Instruct Smoking cessation Safe sex Seatbelt Alcohol abstention Disease specific (diabetes, medication side effects, etc)

Here is a summary of the entire first part of the video (some of this is abbreviated so hopefully it makes sense, but you can watch and read along) CCS Cases
 Things to look for initially (brief skim of H&P) - write these on scratch sheet 1. Age 2. Gender 3. Allergies 4. Brief skim of hx 5. Screening/vaccines/social hx (smoke, drink, drugs, sexual hx) **skimming hx - buzzwords (they don’t want to trick you, dx is sometimes very very obvious) ex: RUQ pain exacerbated by fatty foods - gallstones They want to see if you can put in orders correctly, in correct order, and rule out other scary things (i.e ACS, pancreatitis etc) VS Exam: 1. If pt stable (i.e. in clinic and HDS) - complete physical (especially hitting the things they present with) 2. If pt unstable - not doing complete PE, wastes “simulated” time, need to “act fast” and do a focused PE Disposition - Where do you want the patient to be? 1. Home 2. ED 3. Admit 4. ICU STAT orders - Do you want to place any emergency orders? Mnemonic - MAVOCC + F (not all needed, but reminder of some HY examples) 1. Morphine 2. ACC (gives you IV access and glucose accuchecks) 3. Vitals check 4. Oxygen/oximeter 5. Cardiac monitor 6. C-spine 7. Fluids (NS) Orders (mnemonic) - tailor these tests to your ddx, don’t order all every time for every patient CCCMP CUAEH LLUSCENT 1. CBC 2. CMP 3. Creatine phosphokinase (CPK/CK) 4. Magnesium 5. Phosphate 1. CXR (or any XR) 2. US 3. ABG 4. ECG (other cardiac tests - echo, troponins) 5. B-HCG (repro age like <45-50 yo) 1. Lactate 2. LFT/PT/PTT/INR 3. UA/cx/UDS (or toxicology) 4. Stool cx/pH/Ova etc 5. Culture (blood, sputum etc) 6. ESR/CRP 7. Neuro checks 8. TSH Ex: 20 minute case (real-world time) - Takes you 10 minutes to complete (real time) - You treat pt perfectly - Case will end early - If you get major big things, haven’t done anything super wrong, and pt is improving —> case will end early and you have 2 minutes at the end to put in extra orders **refer back to scratch paper for quick reference for these below 1. Screening tests - i.e. colonoscopy, Pap smear, mammography 2. Vaccines - shingles, tetanus, pneumococcal 3. Counseling patient - i.e. smoking/drinking/drug cessation, medications, compliance, side effects, safe sex (if STI case), seat belt SITPM CPM ISSSAD SITPM Vax - based on case, age, gender etc 1. Shingles - zoster max - >50 yo, 2 dose series, now then in 2-6 mo 2. Influenza/COVID - fall/winter season (RSV >60 yo) 3. Tetanus - q10years 4. Pneumococcal >65 (or susceptible to encapsulated organisms) 5. Meningococcal - 2-dose at 11-12 yo and 16 yo CPM Screening 1. Colonoscopy - 45-75 yo (q10years if no abn) 2. Pap smear - (21-29 yo) q3yr w/ cervical cyto alone - (30-65) q3yr w/ cervical cyto alone, q5yr w/ high-risk HPV testing alone, or q5yr w/ hrHPV w/ cyto (co-testing) - Chlamydia/gonorrhea - all sexually active women <24 yo and >25 yo at increased risk for infection 3. Mammography - 50-74 yo - biennial screening ISSSAD Instructing patient - when you type “instruct” into order search, gives you lots of options 1. Instruct 2. Smoking 3. Safe sex 4. Seatbelt 5. Alcohol abstention 6. Disease specific instructions

Very helpful. Makes CCS feel less overwhelming. Thank you!

This was extremely helpful. Thanks so much for putting this together.

Thank you, found this video the day before my exam, and it helped a ton!

my test is on Monday and this was great!!! you gave me some ideas on how to optimize my time. thanks doc!!

By far the best video on this content. Thank you so much for taking the time to make this!

very helpful!! thank you!

You are an absolute legend.

excellent teaching thanks so much

This was a phenomenal video bro. I used all your ccs mnemonics and tips and passed with ease. Thank You !

Thank you so much for the video. It's really helpful! I don't think you need prophylactic cefazolin on the cholecystitis case as you already started therapeutic piperacillin-tazobactam. Thanks again!

I really needed this video. Thank you so much

Thank you!

Thank you😊😊

thank you!

Thanks!!!

Thanku so much 😊

Thank you so much

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