Saturday, September 13, 2008


The step-3 examination:

Step 3 is a two-day examination. You must complete each day of testing within 8 hours. The first day of testing includes 336 multiple-choice items divided into 7 blocks of 48 items each. There will be 60 minutes of time allowed for completion of each block of test items. There is a maximum of 7 hours of testing on the first day. There is also a minimum of 45 minutes of break time and a 15-minute optional tutorial. Note that the amount of time available for breaks may be increased by finishing a block of test items or the optional tutorial before the allotted time expires.

The second day of testing includes 144 multiple-choice items, divided into 4 blocks of 36 items. These blocks will take 45 minutes. The total time allotted for these blocks is 3 hours. The second day also includes a Primum® Tutorial and instructions for which approximately 15 minutes are allowed. This is followed by 9 case simulations, for which 4 hours are allotted.

visit usmle website for updated information

The CCS:

You will have approximately 25 minutes to complete all expected steps in

management, and for that an organized approach is recommended.

The following is an outline how to perform during the exam:

1. Read the case presentation: Make mental check list of DDx

Physical Examination

2. Order all emergent procedures if required (ABCD's)

3. PE :

Always perform a general, pulmonary, cardiovascular,

abdominal, and extremities examination

Select any other system as suggested by the presentation

4. Write Orders

Laboratory/radiological tests


Procedures (diagnostic and therapeutic)


5. Change Patient's Location if required

6. Continuous Management (screen for risk factors and complications)

7. End Case

a. If patient improves, discharge or change to an appropriate location

b. Make an appointment and continuously follow the patient

Neeraj’s CCS strategy


c. Order appropriate counseling

How to prepare for CCS:

1. USMLE CD: To know about the structure of the exam and a simulator

with 5 patients for you to practice. One of the most efficient ways to

prepare for the CCS is to practice the cases in the simulator and know

how to use the program. The CCS simulator has several keys and

features, and you need to know them very well.

2. USMLEWORLD 88 Cases

3. FA CCS cases: More or less notes of UW cases


My patient did not improve: Did I fail?

Have in mind that the outcome of the patient is not always relevant to your

score. You may find during the CSS that some patients doesn't improve or

can even complicate while standard management is being used.

My case was finished before time: Did I fail?

It has nothing to do with your performance. Your score will depend not only

on you knowing what to order, but to do it in the adequate sequence and

timing as well.

How the CCS scored:

The software considers:

1. The orders you write to make diagnosis and

exclude DDx including all labs and imaging

2. The points you write to treat the conditions

3. How and what you monitor

4. How you change location in appropriate setting

5. Is the timing of all orders correct? Like managing

an ER patient within shortest duration to save his


6. Sequencing

7. Did you order something which was harmful to

the patient or contraindicated in management?

All above mentioned orders are compared with an

ideal approach and scoring is done.

Neeraj’s CCS strategy




Write down the age, sex, chief complaint, and allergies of the patient on the

writing sheet provided at the exam at prometric center

Write down following information:

1. Setting: ER?

2. Age, Race (African American?) & Sex

3. Abnormal vitals

4. Diabetic or not?

5. Allergies, Drugs, Alcohol, Tobacco

6. Important presenting complaints: Including chief complaint and

associated complaints

Age: >50: Colonoscopy, DRE (Male), Mammography (>40), Vaccines,


Female: Pap, Mammo, B-hcg, Chlamydia/GC (write down whatever

applicable and need to be elaborated during the case)

You need to mention all these age/sex specific screening on 5 minute


Abnormal vitals

1. Low BP-Insert IV access and start IV NSS

Cardiac Monitor +

12 lead EKG

2. Increased RR with Dyspnea-Pulse oximetery with Oxygen


Is he/she Diabetic? Don’t forget to Check HB A1c and regular

accucheck. Mention drug compliance, Diabetic foot care, Regular

accucheck, Diabetic diet, Ophtalmology consult for fundoscopy.

Note down the allergies: Never write those drugs.

Associated complaints:

1. Vomiting: IV Pheneragan

2. Constipation: Docusate

3. Diarrhea: Loperamide

4. Severe somatic pain: Morphine (Except CBD stone: Mepiridine)

5. Severe body pain: Naprexone/Ketorolac/Indomethacin

6. Chest pain: Aspirin + Sublingual NG

Neeraj’s CCS strategy



See the Location! Gives clue of diagnosis: Is it an emergency?

Are Vitals unstable? Office presentation with unstable vitals

Send to ER

Emergency Protocol:

Pulse Oximetery

Oxygen inhalation

IV access (Bleeding -2 large bore needles)


Cardiac (Cardio-respiratory) monitoring

Continuous BP monitoring

12 lead EKG

Finger stick glucose

(Write whatever applicable)

Pulse Oximetery

IV access

Above two options might be required in many other settings-ask if it is


Pulse oximetery may be needed almost in 30-40% cases. Write it



Only General + Limited system (Maximum Two systems): It’s an

emergency-don’t waste your time buddy!

Once the patients vitals are


Perform the remaining PE.

Otherwise you may perform relevant PE in office setting

Complete PE !

Laboratory tests: BOUPI Mnemonic


Blood: CBC, BMP, LFT, Lipid profile, PT/PTT, Culture(In every



Other tests: EKG,PEFR (In every asthma /COPD case),Pulse



Urine: UA, Culture, Toxicology(LOC, Poisoning, Acute confusion,





Imaging : X-Ray, USG,CT,MR

Always prefer screening, time and cost effective and noninvasive tests


Confirmatory test can be ordered later e. g Pulse oximetery first

followed by ABG

Any invasive test

Take appropriate consult.

Tx only after confirmatory test is done

Choice of tests: Noninvasive screening tests are always preferred


Think before if you order an invasive test? Is it actually needed

Neeraj’s CCS strategy


Usual Labs and simple tips


Universally written:

1. CBC,

2. BMP

3. Urine routine


1. Always write when H/o any bleeding

2. Or you are going to insert a needle e.g CSF


3. pre-op patient

LFT: Whenever a pain abdomen is there or h/o jaundice

TSH: Suspecting Thyroid problem, Fatigue or dementia, Muscular

pain, Raised LFT’s

Lipid Profile: Nephrotic syndrome,DM,CAD,

Cardiac enzymes: Chest apin,Injury chest

ABG: Severe dyspnea, Altered O2 on pulse oximetery, Acid base


Toxicology screen-Urine: Sudden confusion,Palpitation,LOC

ESR: New back pain,SLE,Sarcodosis,TB

If there is h/o severe bleed: after measuring PT/PTT order

Blood grouping and cross matching

Transfusion when Hb <8(if>

active bleed): Use 2-3 units

If PT> 17 GIVE Fresh frozen plasma

When giving FFT/Blood transfusion stop NSS

If suspecting Infections (sepsis): cultures of Blood, Urine,

Sputum or CSF, as appropriate


Acute abdomen: order amylase, lipase, b HCG & acute abdominal X

ray series


In proper setting

Change the location as per need


Don’t forget to refer allergies before you write Tx

Does it require any tube: NG Tube or Foley’s catheter?

H/o Bleed (Fresh blood thru mouth or per rectum –to r/o Upper GI

bleed) :NG Tube

No urine for many hours: Foley’s catheter(R/o obstruction)

Admit to floor or ICU: Use Mnemonic “ADMIT CO”

Activity: As tolerated/Bed rest Complete (or with bath room privileges)

Diet: NPO/Diabetic /Renal/Low cholesterol or low salt diet

Medications: To discontinue (Metformin etc) or Continue

Input/Output,IV Fluid

Temperatute.BP.RR –Vitals

Neeraj’s CCS strategy


Compression: Pneumatic Stocking

Omeprazole : to protect gastric mucosa/Ranitidine IV

Do Interval/follow-up history: Very essential to know how

patient is improving?

Move the patient as per the need:

When patient is improving follow:





When the patient deteriorating:





Aggressive Treatment

Remember First stabilize, then full physical, and then admit

Do not send patient to home immediately-admit him(can be for one

day only)

Breathing difficulty: Pulse oximetery, order Oxygen, albuterol PRN

Unresponsive state: Check finger stick glucose stat, naloxone given if

opiates are suspected (Pupils), and thiamine added to IV fluids if


Overdose/poisoning: Admitted to the ICU

for closer monitoring

and suicide precautions. Don’t forget to get a Psychiatry consult,

Sucidal contract and precautions.

In the

ER setting

, first do a brief physical exam (2 min).

Once the

patient is stabilized and lab results reviewed, do a full physical

exam. Then shift the patient to the ICU or ward.

Then write orders and labs. Do not write entire panel like BMP-Be

specific for test in ER(To save time)

Acute abdomen and most surgical emergencies need frequent and

multiple interval H&P.


Counseling is a major part of outpatient office visits. Pay particular

attention to counseling in normal/ routine patient visits. Important

counseling topics include smoking, alcohol, drugs, safe sex

practices, exercise, weight reduction, diet, and self-breast exam.

Patients with Hypertension and diabetes should have appropriate

diets ordered (2 gm salt restricted or 1800 ADA diet)

For abnormal LFTs order a hepatitis profile/panel if appropriate.

USMLE CCS exam assesses the appropriateness of medical orders.

Order tests to diagnose H. pylori if patient has GERD. The

H. pylori


should be ordered if the patient has never been

diagnosed before and the

Urease breath test if checking for

elimination/ recurrence.

In patient:

Inpatient hospital admissions need a physical exam everyday and

appropriate lab and medical orders.

Neeraj’s CCS strategy



Counseling at 5 minutes screen: RATED SEX

1. Reassurance

2. Alcohol-No

3. Tobacco-No

4. Exercise regularly

5. Drug compliance/No recreational drugs

6. Seat belt

7. Educate patient/family

8. X factor is -Sex (safety)

9. Mention all screenings and vaccines-if applicable as per sex &


Pediatric patient: Modified RATED SEX:

1. Reassurance

2. Safety plan

Helmets when Bicycle riding


3. Educate patient/family

4. vaccines

DTaP - 2 months, 4 months, 6 months, between 15 and 18 months, between

4 and 6 years.

IPV - 2 months, 4 months, between 6 and 18 months, between 4 and 6


Hepatitis B - Birth, 2 months, 4 months.

H. influenza B - 2 months, 4 months, 6 months, 12 to 15 months.

Pneumococcus - 2 months, 4 months, 6 months, 12 to 15 months.

Varicella - Between 12 and 15 months.

MMR - Between 12 and 18 months.

Birth 2 4 6 12-15 15-












P/ P/ P/ P/

Neeraj’s CCS strategy


Important Tips:

Patient seen in office setting

Keep him in office and schedule

appointments as per the results of tests available

unless it is

essential to shift into ER or ward.

Patient seen in ER

Try to manage there first

Shift to operation

theater or ICU as per the need.

When writing orders, you can save time by holding down control and

selecting multiple orders with your mouse.

Don’t forget to advance the clock you will not get results and nothing will

happen until you advance the clock.

Advancing the clock: Before you advance the clock to get the results


think-can anything else can be done in this duration

? Like you did

limited examination in ER setting, now it is the time to completer

remaining PE, this will advance the clock automatically. Avoid advancing

clock just to get results, unless nothing else is remaining to perform.

Get appropriate consults. You will get credit for this. However, once you

ask for a consult, the computer may ask you to manage it yourself

temporarily, as the consultant is busy. Don’t worry. Do the routine pre-op

stuff and stabilize the patient. Obtain consult: Any invasive investigation

or procedure(Surgery, Cardiac catheterization, Orthopedic

colonoscopy),Suicidal attempt, Drug overdose

While admitting-don’t forget ADMIT pneumonic: Type “Diet”, it will give

you all options like NPO, diabetic, low salt, low cholesterol etc.

Interval history: Never forget to click over

PE/History button frequently in ER/Admit patients.

It doesn’t harm at all. Rather you will know how

your patient is improving or what else is required.

Also perform the same whenever a patient returns

for an appointment.

Follow up tests at later date can work only on 5 minutes screen.

LFT/lipid profile commonly employed to know side effects of medications.

RATED SEX mnemonic can be ordered on every 5 mints screen just by

typing “counsel”-after that use Ctrl button to choose multiple options of


Neeraj’s CCS strategy


Do not forget to mention all age and sex specific screenings on 5 mints

screen (Which you wrote initially in step-1 as described above).

Avoid un-necessary invasive procedures.

Transfer from office to ER/ICU or ward:

1. Unstable vitals-transfer to ER

2. Alarming reports: To ICU/Floor

3. Pneumonia/PID/Pyelonephritis case meeting admission criteria

Order of procedure is possible on office visit also (You do not need to

admit to get procedure done)

Simply consult the specialist



See the day/time of availability of result


appointment accordingly.

Scheduled the appointment later but received alarming results

Can call

patient even before

Click over “Move patient icon”

Need ICU transfer and its already 5mints screen?

You may still transfer

it to ICU !

Young lady : Order B-hcg,CBC,BMP,UA

Fever/infections: Blood Cx, Urine Cx (Add CSF is


Don’t forget to advance clock by 1

minutes after Blood culture

before you start


For emergency cases, the clock should be advanced

"with the next available result" as management

may change with individual results

Change of location:

1. Office setting: Follow ups

Use obtain result/See patient later button to

schedule appointments

usually prefer a day when all results of tests are

available (No need to use change location button)

Do not forget that

office is open Mon-Fri

So do not give appointment on Sat/Sun.

2. ER setting: Try to deal the case maximum in ER itself

Transfer to

operative room or ICU as per the need


Home least preferred

place from ER.

3. Shift to ICU if hemodynamically unstable

In pain abdomen keep DDx of AMI and perform ECG/Cardiac


In a case of domestic abuse

: Unless the patient states she has alternate

living arrangements,

she should be


to the ward for her

Neeraj’s CCS strategy


own safety


She should not be discharged until appropriate social

services intervention can be arranged

Don’t forget

consult, social

services and advice safety paln

Patients with

foreign body aspiration or anaphylaxis

are generally


to the hospital for observation to monitor for

complications. Discharge depends on the individual clinical course.

Fatigue case orders:

1. CBC

2. BMP

3. UA

4. TSH

5. Fasting Glucose

6. LFT

7. Depression Index

In any anemia do not forget to r/o co-existing iron deficiency anemia with

Iron, TIBG, ferritin level

after therapy watch response with Reticulocyte


Pain abdomen case order:

1. CBC

2. BMP

3. UA

4. LFT

5. Lipase

6. Amylase

7. Abd X-Ray acute series

8. X-ray Chest PA

9. ECG + Cardiac enzymes


11.Add Mepiridine(RUQ)/Morphine + Metoclopramide for nausea/vomiting

MVA case order:

1. CBC

2. BMP

3. UA

4. LFT

5. Amylase

6. Lipase

7. X-ray Pelvis

8. Ultrasound or CT abdomen

9. X-Ray Abd Sup.Erect

10.X-ray Chest


12.Cardiac Enzymes

Neeraj’s CCS strategy


Any cardiac risk assessment required: Lipid profile, fasting


Going to insert needle in body e.g Lumbar puncture,

Thracostomy. Arthrocentesis?

Check PT/PTT

before you do that!

Respiratory trouble? Remember Suction of secretions,Nebulized Albuterol

+ Ipratropium + IV Mehylprednisolone, PEFR/PFT/FEV-1,Chset

physiotherapy/Percussion therapy,ABG’s

Order whatever applicable

In any severely ill patient or infection like

Meningitis/Febrile neutropenia examine the patient

with interval history + CBC/BMP q 6hrly


improvement occurs

After that q12 hrs

Same is applicable to H & H in bleeding state or MVA

i.e. q 6 hrs till improvement


IV drug abuser/HIV/High risk sexual behavior

Also evaluate for


When to transfuse blood? Hb <8>


Any bleeding like nose, Vaginal, Rectal, Upper GI or bruising


When PT is increased add oral Vitamin K

If both PT/PTT increased add


Whenever you inject FFP/Transfusion

Stop IV NSS for

the time being and restart later on.

In every seriously bleeding patient insert TWO large bore

IV needles

Any body NPO or on NSS due to instable

homodynamic should be restored back to oral food

and fluid once he acquires normal BP/HR(120/80 &


Neeraj’s CCS strategy


No urine?

Insert Foley’s first

even though you know it could be


When acidosis(Hyerosmolar coma/DKA) associated with Hyponatremia

use 0.9%NSS but when it is associated with Hypernatremia or Normal

Na+ levels use 0.45% NSS

Dextrose + Insulin is used when K+ is more

and you need to push it intracellular like Rabdomyolysis(DKA use NSS

with Insulin)

Falling BP in serious conditions like

(TSS/Anaphylaxis) not responding to NSS

Give IV


5 mints screen:

Note all IV orders

Convert them into PO or cancel

Is the patient eating

Make him eating by mouth and order

appropriate diet

Any essential treatment you forget to mention? Order it now!

Order all follow up tests now(Later date orders) like LFT/Lipid

profile to assess drug side effects etc

Also order all age/sex specific screening tests and vaccines

RATED SEX (Modified in pediatric patient)

Pls ascertain about

habits like smoking, alcohol or drugs etc before you counsel.

Neeraj’s CCS strategy



dr viral doshi said...

neeraj's strategy is amazing..thanks..u forgot to write 12th stragey???

harshit said...

those are page numbers