u/Mothandaflame

Hey everyone!

For background, I am a PGY-2 FM. I am not the best taker but tbh, I also get bored with Qbanks. Anyway, my Step 1 in 2022 was 225, Step 2 in 2023 was 220 and Step 3 2026 was 220. You can say I am consistent LOL.

I was aware I had a lag between my Step 2 and 3 so I had to revise things. I also knew I have to rebuild foundations due to low scores prior. Residency year 1 really helped me make sense of a lot of clinical stuff tbh especially with inpatient months. I have used the threads here for help and this is my way of giving back. My CCS cases were higher on the score report. I did 90 cases. Reviewed a few. One case was straight from CCS cases.

You can CTRL C and V orders. But for me it wasn't until the 4th case that I had time to write them all first before copy/pasting it. Did it during a 20 minute case.

Did not take any Self-assessments. Took me on-off 3 months studying but really I truly studied in the last month. Having a gap between both days was CRUCIAL. Wouldn't recommend otherwise.

In the Google doc, I snipped the recent FA and only have FA pharm and Rapid review sections to peruse through. That's the only thing I did from FA. Also have some images, USPSTF guidelines, my own Step 3 CCS notes modified from someone else's notes here.

I used Amboss but didn't complete the full Q Bank. As others stated, please do all the HY concepts including risk factors, step 1, step 2 and nutrition. I found out about them too late.

Additionally, I did a few episodes of
1: The USMLE guys popdcast drill sessions - choose your weakness lol. I did psych and genetics.
2: Divine podcast - I think his most recent pharm sessions are great. Listened erratically only
3: This was by far the most helpful EKG video I have seen. Review it.
Conan Liu EKG video https://youtu.be/yLhO60Us3bo?si=csSyW1L7q-PvQll-
4: https://drive.google.com/drive/folders/1bmZ1rWA9PBwdu_QV2rQMyC5jSj0YNp8M?usp=sharing
5: Only Randy Neil for biostats and genetics
6: Saw the whole of Sketchy Micro again.
7: Here was my CCS cases workflow dervied from Khalemedic YouTube video, Reddit and my own personalization based on my CCS cases review/performance:
CCS cases:

Here

1. 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 a case's introduction

Age
Gender
Allergies
VS

3. Brief skim of 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)

Main HPI points: Screening (vaccinations, Pap smear, colonoscopy, etc)

4. Complete physical exam --> if patient is stable or in the office;
   Focused physical exam --> if the patient is unstable or in the ED, you can always do a complete PE later in the case after putting in emergency orders!

5. Disposition 1. Home 2. ED 3. Admit 4. ICU

6. Emergency Orders:

7. STAT orders - Do you want to place any emergency orders? Mnemonic - MAVOCC + F (not all needed, but a reminder of some HY examples)

8. Morphine/metoclopramide/Tylenol/Ibuprofen?

9. ACC (gives you IV access and glucose accuchecks)

10. Vitals check Q4

11. Oxygen/oximeter

12. Cardiac monitor

13. C-spine

14. Fluids (LR)

Norepinephrine??

Finish the rest of the physical exam

7. Routine orders:
   CCCMP - CBC, CMP, Creatine phosphokinase, Magnesium, Phosphate
   CCUAAAEETH - Chest x-ray/CTA/P, other x-rays, Ultrasounds, Abd x ray, Alcohol, A1c/ ECG/echo/trop, hCG
   PPLLLUSSSCENTTy - PT/PTT/INR, Lactate, lipids, lipase, Lyme?Urinalysis/culture/toxicology/microalbumin/gram stain, Serum tox, Stool, sputum culture/pH/ova/etc, Culture (blood, throat, strep), ESR/CRP, Neuro checks, TSH, Type & Screen, Rh

For special stuff: ABCSWEP- autoimmune [antibody, C3, C4], BNP, CSF, GC, HIV, Hep B, C, HSV, trichomonas, wet mount/gram stain, wound culture, EMG, PFT

8. Vaccination
9. Screening
10. Counseling

SITPM

CPGCMD

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 >50 (or susceptible to encapsulated organisms)
5. Meningococcal - 2 doses at 11-12 yo and 16 yo

CPGCM-DUC (screening tests)

1. Colonoscopy (45-75 yrs, every 10 years)
2. Pap smear
3. (21-29 yo) q3yr w/ cervical cyto alone
4. (30-65) q3yr w/ cervical cyto alone, q5yr w/ high-risk HPV testing alone, or q5yr w/ hrHPV w/cyto
5. Chlamydia/gonorrhea - all sexually active women <24 yo and >25 yo are at increased risk for infection
6. Mammography (50-75 yrs, every 2 years)
7. Dexa scan
8. Ultrasound for AAA screening
9. CT lung for smokers

ISSSADD-CPS (counseling); when you type “instruct” into order search, it gives you lots of options:

Instruct: Smoking cessation, Safe sex, Seatbelt, alcohol abstinence, Disease-specific (diabetes, medication side effects, etc.), no Drugs, exercise

Med compliance, public health, social services

Reassure pt

Advise patient of side effects of medication

Counsel pt, med use

counsel cancer diagnosis

11. Final mnemonics:

MAVOCC + F
CCCMP
CUAAAEETH
PPLLLUSSSCENTTyRh
AutoBNPCsfStdWoundEmgPft
SITPM
CPGCMDA - AAA/CT
ISSSAD

Stroke- consult IR, neuro, vascular surgery, Carotid USG, CT, CTA

Intubate + mechanical ventilation always, 2 orders

12. If admit

A: Antidiarrheal – loperamide, Antibiotics + Ambulatory or
B: Bed rest
D: Diet (diabetic, low salt, NPO, regular, cardiac)
D: DVT prophylaxis (LMWH, compression stockings)
E: Elevate head end of the bed
F: Foley and “urine output”, fluids
G: Gastric tube if needed
L: Labs (e.g., BMP, CBC q24h)
P: Pain - Morphine, NSAIDs, or acetaminophen
P: Stress ulcer prophylaxis (PPI)
N: Nausea – Zofran, Phenergan
N: Neurochecks if disoriented
S: Suction airway if comatose or disoriented
V: Vitals (Q1, Q4, Q8)

13. Surgery pre-op orders: NICE PT (on surgery table):

NPO
Informed consent
Cefazolin (+ any other antibiotics!)
ECG
PT/PTT
T&S (unsure what this was)

Name of the surgery (if surgeon doesn’t accept, you’re probably missing some tests necessary to qualify them for surgery, or they don’t need surgery).

If female and pregnant, Rh type should be done as well.

Good luck! :)