Step 3 CCS - Golden Advice

Best way is to practice the software as many times as you can. Here's something to help you on your approach for CCS exam.

LOGICAL APPROACH TO ANY CCS CASE :

First ------ Take a deep breath and select 'Start Case' button to begin.
You will see the case introduction.
Wait!
Note on the erasable board:
1. Setting
2. Age of the patient
3. Race of the Patient
4. Sex of the patient

Then click 'OK' and you will see the initial vital signs.
Wait!
Note on the erasable board: Stable or unstable?
Then click 'OK' and you will see the initial history.
Wait!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Think !!!!!!!!!!!!!!!!!!!!!!
and write on the erasable board: Differential Diagnosis : Allergies Habits – smoking , alcohol , drugs , etc. Anything worrisome?
Then ask: Is the patient stable or is it an emergency? A clue to this would be in the history - for emergency cases, you will see only the basic history of present illness and not the detailed history (social, past, etc). All other history will be 'unobtainable'.
If unstable, do a EMERGENT physical exam. No emergency case should get a full physical exam - it's an emergency!! For the EMERGENT physical, choose the 'general appearance' and the relevant system. If needed, add one or two relevant systems.
After you note the results of the EMERGENT physical, stabilize patient immediately: Airway – Intubation? Breathing – Oxygen mask? Chest tube? Circulation – IV fluids? Dopamine? Drugs – Naloxone? Dextrose? Thiamine? IV Access?
Then ask: Does the patient's condition correlate to the setting? Emergency or unstable patient in office needs to go to the ER immediately!! Change location if necessary. After the patient is stable and in the right setting, proceed to 'Interval/follow-up history' and a more detailed RELEVANT physical exam.
BUT If the patient is already a STABLE case in the right setting, proceed straight to the RELEVANT physical exam. Then ask: Is the case limited to one particular system? Like Asthma or MI? Choose the particular system and a few related systems, based on the most likely diagnosis. Is the case not limited to one particular system?
Choose a COMPLETE physical exam. This option is available on the top of the physical exam choices. Examples of such cases include Case for Annual Physical Exam, Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc. Note the significant findings on the physical exam and go back to your erasable paper and revise your Differential Diagnosis. Strike out those which are less likely and add those are more likely.
Then -- keeping the Differential Diagnosis in mind, consider the labs to be done. When considering labs use this mnemonic:
I B U O P
I – Imaging –> X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.
B – Blood –> CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.
U – Urine –> Urinalysis, Toxicology Screen, Ketones, etc.
O – Others –> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse oximetry, Biopsies, etc.
P – Pregnancy test –> For any female of reproductive age presenting with abdominal or pelvic symptoms, or trauma.

When ordering labs, consider:
Is this test time-effective/time-consuming? Choose time-effective.
Is this test initial screening/confirmatory? Choose initial screening.
Is this test cheap/expensive? Choose cheap.
Is this test non-invasive/invasive? Choose non-invasive.
Then ask:
Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the above criteria but will not tell you anything useful.
Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat Chloride test for Cystic Fibrosis, etc.
Are the tests in the right order? Example – Pulse Oximetry before ABG, CT before Spinal Tap, etc. Order the labs using the Order button.
Then advance clock to the 'Next Available Result'. Understand the results.
Ask: Is the diagnosis clear or do I need any confirmatory tests? If diagnosis is clear, start treatment. If confirmation is needed, order confirmatory tests and then start treatment. Treatment :
Determine if the patient is in the right setting. If patient is in office and needs to be admitted, change location to ward. If patient is in ward and is in a serious condition, change location to ICU. If case is admitted, order: IV access (unless IV drugs are not indicated) – Type 'IV Access'. Vital Signs – Type Vitals and click on 'Every 1,2, 4 or 6 hours' depending on the condition of patient. Activity – Type 'Bed Rest' and choose 'Complete bed rest' or 'Bed rest with bathroom privileges' or type restrain and choose 'Restrain patient in bed'. Diet – Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order 'Diet' and you will see the list of options, choose which is the best for this case. Tubes – NG Tube? Foley's catheter? Fluids – Saline, Ringer, etc. Type 'Fluids' and choose which is the best for this case. Urine output – Type 'Urine Output' and choose frequency. There is no option for Input/output chart. Medications : Stop! Check for allergies on erasable board! Order standard drugs for this case. Decide IV or Oral. Decide bolus or continuous. Decide frequency. Labs : Additional labs to confirm diagnosis? Labs to monitor? Cardiac Monitor? Pulse Oximetry? Consults : Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.
Then move clock!
Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1 week.
Do Interval/follow-up history. Understand the results of the labs. Then ask: Has the patient's condition changed significantly? If yes, change locations.
If the condition has improved, move the patient to the next location in the order ER --> ICU --> Ward --> Office/Home.
If the condition has worsened, move the patient to the next location in the order Home/Office --> Ward/ER or Ward/ER --> ICU.
If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home): Stop unnecessary medications and change IV medications to oral. Discontinue IV fluids. Remove tubes. Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant. Patient education or counseling or diet specific and vital to this case.
Type 'patient education' and 'counsel' and see if anything is relevant to this specific case.
Type 'Diet' and see if anything is relevant to this specific case. By this time, the 5 minute screen will appear!
Then type 'counsel' and choose the relevant things. You can choose multiple things at a time. See your erasable board for any worrisome habits like alcohol or smoking!
Type 'patient education' and choose the relevant things. You can choose multiple things at a time