Usmle step 3 ccs cases - step by step approach


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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.
  1. 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.
  1. 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 stab
    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