USMLE STEP 3 CCS CASES - STEP BY STEP APPROACH

Dr. Ashish Shrivastava

1. OFFICE CASE

• Physical Examination.
• Routine orders + Specific orders.
• Nothing urgent - Send the patient home and follow up according to result date.
• Results – 1) Normal – Reassure the patient.
2) Abnormal – Further tests or specific treatment if diagnosis clear.
• Interval history if required.
• Counsel the patient + Vaccination(age appropriate).
• Follow up at appropriate duration(mostly 2-3 months).
• Final Diagnosis.

2. EMERGENCY CASES

(a) Acute Emergency

• First stabilize the patient.

• Focussed physical examination.
• Routine orders + Specific orders.
• Specific treatment + symptomatic treatment in Orders only.
• Treatment interventions based on test results.
• Shift to Ward/Inpatient services.
• Post op orders.
• Follow up for a week.
• Shift to Home & follow up.
• Counseling.
• Final diagnosis.

(b) Non-acute emergency

• Stabilize the patient if required.

• Focussed physical examination.
• Routine orders + Specific orders.
• Specific treatment + symptomatic treatment in Orders only.
• Shift to Ward/Inpatient services.
• Treatment interventions based on test results.
• Follow up in ward till patient stabilizes.
• Shift to Home & follow up.
• Counseling.
• Final diagnosis.
STABILIZING ORDERS

• IV Access.
• IV Fluids.
• Normal Saline(NSS).
• O2 inhalation.
• Pulse Oximetry.
• Cardiac Monitoring.
• NPO.
• Cx spine immobilization.
• Glucose levels.

ROUTINE ORDERS

• CBC with differentials.

• BMP.
• EKG.
• ABG.
• UA.
• CXR.
• TSH.
• Orders related to the illness – Acetaminophen(Fever), Phenergan(Vomiting),
Morphine(Pain).

POST OP CARE

• NPO.
• Bed rest.
• Vitals.
• Urine Output.
• Recheck BMP.
• Pneumatic compression.
• Pantoprazole.
• Telemetry.
COUNSELING

• No smoking.
• No Alcohol.
• Safe sex.
• Regular exercise.
• Seat Belt.
• No illicit drugs.
• Diabetic teaching, diabetic foot care.
• Alcohol anonymous.
• Pregnancy counseling.
• Parent counseling.
• Medication Adherence.
• Cancer Diagnosis.
• HIV support group.
• Cancer-oncology consult.

UNCONSCIOUS PATIENT

• A – Airway suction, pulse oxi.

• B – Breathing-Endotracheal intubation.
• C – Cardiac-IV access, cardiac monitoring, foley’s placement, finger-stick glucose, 0.9 NS,
ABG.
• D – Decontamination-Thiamine, dextrose, naloxone, urine toxic screen, blood alcohol
levels.

ALCOHOL WITHDRAWAL

• IV THIAMINE.
• IV FOLIC ACID.
• Lorazepam, Haloperidol(Agitation).
• Blood glucose Levels.
• EKG.
INTOXICATED PATIENT

• Urine toxicology screen.

• Blood Alcohol Levels.
• IV fluids, Dextrose if hypoglycemic.
• CBC, BM, LFT, PT, PTT..
• EKG, ABG, CXR.
• S.Mg, S.PO4.
• Frequent neurological examination.

PREGNANCY

• B-hCG.
• Trans-vaginal USG.
• Blood type, Rh, CBC, BMP, PAP smear, UA, Urine culture, Rubella Ab, RPR, HBsAg,
HIV, Chlamydia.
• Prenatal vitamins, Ferrous sulphate, Folic acid.
• Follow up with Pelvic USG.
• Counseling.