steveme

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    CCS is considered very important for passing Step 3. Despite this, most of us do not place enough emphasis on this. There are so many things we do not notice on software because of not knowing or not practicing enough. Often what our mind does not know, our eyes do not see. I am starting this thread hoping to have a dynamic discussion on CCS to keep myself involved and updated. Most strategies posted here are from my own understanding and what I gathered from going through ********** videos and Step 3 online forums.
    Please feel free to contribute to this thread.

    CCS tip #1
    Anything that you manually type in to the blank box is not picked up and scored by software.
    1. Diagnosis is not scored
    2. Reason for consultation that you type in the box is not scored but you must state reason for consultation by selecting and placing an order
     
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    steveme

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      CCS Tip #2
      Make sure you Monitor not just order tests. Monitoring efficacy and safety of your interventions is very highly scored on the exam. Monitoring is both active and passive. Passive monitoring runs in the background based on the generic orders you placed at the beginning of the case. We get scored for this.
      Monitoring is also both immediate as well as "Later" Later monitoring is done by calendar option. Very crucial to use Calendar option on 2 min screen to do Later monitoring.


      From source : " Monitoring is very important and high score goes to different sections of monitoring. You should monitor efficacy of drug or procedure and side effects of drug
      for example, ordering cxr after putting chest tube in tension pneumothorax is monitoring the effect of that intervention - chest tube.
      While you have to order such monitoring after intervention, some clinical and lab monitoring can occur in the background automatically if you set a frequency
      examples : monitoring in altered mental status - Neurochecks every 2 hours
      monitoring septic shock : continuous BP , Arterial line, CVP monitor q2hrs; mixed venous oximetry q2hrs
      monitoring shock patients on pressor: put arterial line and select continuous BP monitoring
      Monitoring DKA : glucose q1hr and BMP q4hours
      So, you just put in these type of orders along with your initial order set so they keep running in the background as you advance the clock and gets you score for monitoring ..
       
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      steveme

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        The TWO-MINUTE SCREEN/ CASE- END SCREEN

        The two min screen is for placing important orders that are highly scored. It is mostly meant for monitoring and setting up follow up appointments.

        I would like to list the guidelines from ********** course.
        ********** summarizes two min screen strategy in to a couple of simple things : 1. Monitoring Orders 2. Case-specific screening orders 3. Case-specific important counseling orders.

        1) If you started an intervention during the active screen, you will need to monitor that intervention most of the times. On 2-min screen, there is a calendar option specifically to set up monitoring orders. Monitoring can be two types a) monitoring for efficacy or b) monitoring for toxicity.

        Efficacy monitoring examples a) You started a Statin in hyperlipidemia case. You want to place an order for Lipid panel in 1 month. You order Lipid panel and go to calendar and choose date 30 days away. Remember you can do this only on 2-min screen. You can not do this on active screen since you have no way to set up orders to take place at a "later" date. b) You treated a patient with an acute MI during active case and his EF was 30%. You want to set up a repeat ECHOcardiogram in 3months to see if EF has recovered. You set this up using later option on 2-min screen.
        Apparently, all these are very highly scored. It makes sense since this is exactly what Step 3 is testing - not just diagnosis and treatment but also, monitoring.

        Toxicity Monitoring examples: a) You started a Statin in hyperlipidemia case. You want to place an order for Liver function tests in 3 month. You order LFTS and go to calendar and choose date 90 days away.
        b) You started INH in a Latent TB case who is also alcoholic. You probably already obtained baseline LFTs on the active screen. When you reach 2min case-end screen, you must not forget placing an order for LIVER FUNCTION TESTS in 1month.
        c) You started Methotrexate in RA case. Since adverse effect is hepatitis, obtain LFTs in 3 months by choosing "later" option on 2-min screen. As per 2008 ACR recommendations, LFT monitoring at an interval of every 8 to 12 weeks is appropriate after three months of therapy and monitoring every 12 weeks can be performed beyond six months of therapy.
        Methotrexate is a well known cause of acute clinically apparent liver injury which can be severe and is sometimes fatal - I know a rheumatologist that got sued because of not placing such monitoring order in real life practice. Now this is exactly what Step 3 is testing for. You can not miss certain monitoring orders which if missed can be potentially life threatening - you will get negative scoring for missing this on Step 3 CCS.

        Next posts:Will detail other 2-min screen functions
         
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        steveme

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          A list of important CCS cases to solve:
          1. DKA
          2. Pulmonary embolism
          3. Endometrial carcinoma
          4. 1 day old Newborn Down’s baby presenting with vomiting/ Duodenal Atresia
          5. Motor vehicle accident with splenic rupture
          7. TIA
          8. Acute Hepatitis A
          9. Secondary Hypertension, Hypokalemia – adrenal mass
          10. Minimal change disease: Child had scrotal swelling.
          11. Constitutional growth delay in african american kid
          12. Pericarditis
          13. VSD
          14. Acute MI
          15. Osteoprosis with compression fractures
          16. Gastritis secondary to NSAIDs use
          17. New Onset DM type II
          18. Pregnancy
          19. Anaphylaxic reaction/ Shock
          20. Adrenal Mass/ Hyperldosteronsim/ Hypokalemia/ Young woman presenting with leg cramps & weakness
          21. Heat Stroke
          22. Ovarian Teratoma
          23. Inflammatory Bowel disease
          24. Vaginal Bleeding secondary to Fibroids requiring hysterectomy. ( Woman 44 y/o)
          25. cervical cancer26. Turners syndrome
          27. UTI/Sepsis – 76 Y/o woman sent from NH for evaluation of altered mental status
          28. Hepatic encephalopathy
          29. Acute Cholecystitis
          30. G6PD deficiency
          31. Constipation, hypercalcemia, primary hyperparathyroidism
          32. Pregnancy with asymptomatic bactiriuria
          33. Back pain due to osteoporotic fracture – compression fracture
          34. Bipolar disorder
          35. Plulmonary embolism
          36. Abdominal Anuersym Rupture presenting with backpain/ No Hypotension at presentation – Vitals stable, so you can get CT scan and then surgery consult.
          37. Chalymadia trochmatis (in a male)/ Non gonococcal urethritis
          38. Erosive esophagitis/ GERD
          39. Panic Attack
          40. Acute Asthma Attack – 14 Y/O female with wheezing, Sob
          41. Obesity in a teenager
          42. Toxic Shock syndrome/ Tampon use
          43. Hyperglycemia/ new onset DM Type
          44. fracture neck of femurs – 75 y/o female fell and sustained right hip fracture – Ortho consult, ORIF, fall prevention, hip protection devices, Osteoporosis screening, DVT prophylaxis
          45. HIV with pcp and lymphoma
          46. child abuse with sub dural hemorrhage
          47. Tylenol overdose
          48. Heat Stroke
          49. Acute PID
          50. Tricyclic Overdose {40 y.o. Arab male with no history know brought in the ER by a neighbour with uncounciousness and unresponsive state – he had some depression as per neighbour (TCA TOXICITY)}
          51. Acute pancreatitis
          52. Child with intusussception
          53. Woman with multiple sclerosis ( comes with weakness and has nystagmus on neuron exam)54. Septic pulmonary emboli in IVD abuser.
          55. Stable Angina
          56. SLE
          57. Pregnancy in a 44yr old women
          58. Bacterial Meningitis in an infant
          59. Juvenile Rheumatoid Arthritis
          60. Anemia secondary to colon cancer
          61. Alzheimer’s Disease(had to rule out other causes of dementia before makingthe diagnosis)
          62. 50 + y.o. M with epigastric pain (erosive gastritis, had h/o long term NSAID use) – Has age criteria for EGD.
          63. 40 y.o. M with IVDA and SOB with fever (Infective Endocarditis)
          64. 4 yo. F with ANA +ve Arthritis65. 50 + y.o. F with high BP in office
          66. 50 + y.o. F with Renal failure and family h/o ADAPKD, HIGH K+
          67. Acute manic disorder
          68. UTI with 12 week prenancy
          69. chid abuse
          70. acute diarrhea
          71. Acute MI
          72. CHILD ABUSE : 2 y/0 AA boy was brought with lethargy, CXR revealed multiple posterior rib fractures and CT head subdural hematoma —Child abuse, call child protection services and social work consult
          73.) Eclampsia… presented with seizures and peripheral edema at 38 weeks pregnancy.( Magnesium sulfate, induce delivery, if still seizure – follow status protocol)
          74) Uncontrolled DM type 2 – came with increased thirst and urination
          75) HIV in a 25 y/o f with multiple partners – came with weightloss, fatigue and cough. Do HIV test, viral load, genotyping. Then cd4 count.
          76) Acute pericarditis.
          77). Right upper quadrant pain, cxr – pneumonia – right lower lobe – community acqd pneumonia
          78) Dysfunctional uterine bleeding
          79) Polymyalgia reheumatica
          80) Trauma patient with cardiac tamponade
          81) Pancreatic ca, old man with fatigue, weightloss – exam shows icterus – go ahead with CT
          82) 9mos old baby with fever unknown cause all tests including cbc are negative ( Roseolum infantum)
          83) hypothyroidism in a man
          84) Post menopausal bleeding in a woman not on HRT/ benign endometrial hyperplasia85) cystitis
          86) septic arthritis
          87)gastric carcinoma
          88)incomplete abortion
          89)Atrial fibrillation
          90) Diverticulitis
          91) Dehydration/ Hypernatremia
          92. 20 month old african american boy brought for fatigue and lethargy to office/ Fe deficiency
          93. Acute Bacterial Prostatitis
          94. ALL in a 5 year old/ 5 yr. old boy who came with weakness, disinterest in activity and lesion on leg.
          95. Acute pericarditis – rx ( make sure to do echo, dont do unnecessary pericardiocentesis if there is mild to moderate pericarditis with out clinical or echocardiographic evidence of tamponade)
          96. Osteoarthritis of the Knee ( if there is large joint effusion, always do arthrocentesis)
          97. CIN III
          98. Congestive heart failure in a post-op patient ( make sure they are not giving too much IV fluids in post op setting, I/O monitoring, daily weights, lasix, 2d echo, r/o MI, EKG, CXR, BNP – Lasix, if flash pulm edema, give morphine)
          99. Hypercalcemia/ renal mass ( likely RCC) – Elderly man presenting with fatigue
          100) Complete Heart Block - Woman coming with Motor Vehicle Accident/ only minor injuries on the arm , Vitals reveal Heart rate 38. - EKG shows complete Heart block
           
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          steveme

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            CCS Tip # 4
            Consultants give a real response on the exam if you meet criteria for surgery or procedure. You will get a response "Patient will be scheduled for surgery, proceed with Medical management".
            Sequencing is important to make consultant give real response.

            From source on SDN forum: Step 3 CCS/ consult . UWorld CCS does not tell about sequencing of orders and did not incorporate this sequence in to their software algorithm. Exam step 3 software is cleverly designed to change surgeon's responses based on sequencing of your orders. You can practice the following example on NBME exam software and see how surgeon's response changes. Per demonstration shown on ********** video. Step 3 software tests us if we are capable of meeting Surgery criteria before calling a Surgeon. If you do a surgery on a patient who does not meet criteria, it will fail us because we are removing an organ from a patient or invading a patient who does not need it. With regard to what Archer showed, he gives a clear example in aortic dissection case on the step 3 software how surgeon accepts the case when criteria is met ( CT scan results show ascending dissection and then we should sequence consult order). In the same case, he calls surgery consult before ordering a CT and the surgeon says "no recommendation" . He calls surgeon after ordering CT and after result comes in for the CT, then same surgeon accepts and says "patient will be scheduled for surgery". So, it is important to sequence orders to meet surgical criteria first and then call surgeon if required. The criteria for surgery in dissection is the location - ascending aorta - CT needs to be read before calling a surgeon.
            Source : SDN forums
             
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            MOH

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              Hello,
              This question is with respect to cases ending early. I had kind of a basic question. Once the 2 min screen comes up, can we add meds for treatment of the patient's problems or even consults on that screen at that time. I am concerned what to do if the case ends prior to my pharmacotherapy and/or consults. Any insight would be appreciated. Thank you.
               
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              steveme

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                @steveme this is great. I'm planning on taking my exam at the end of August. I hope you'll continue to provide more tips.
                I am glad that these are helpful. I have extracted them out of ********** so do not want to claim that these are my own :)
                I have not logged in here for a few weeks so just checked your message. Yes, will continue to post the tips.
                 
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                steveme

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                  Hello,
                  This question is with respect to cases ending early. I had kind of a basic question. Once the 2 min screen comes up, can we add meds for treatment of the patient's problems or even consults on that screen at that time. I am concerned what to do if the case ends prior to my pharmacotherapy and/or consults. Any insight would be appreciated. Thank you.

                  Hi MOH, this is a great question. Yes, we can add the medications on 2-min screen. It is important to prioritize the actions on 2-min screen because we have very less time. Orders for screening tests and some routine orders such as diet are not even scored. Priority should be placed on:
                  a. Entering any necessary treatment orders that you were unable to enter on the active screen.
                  b. Adding consult requests that are crucial. Eg: Surgical consult for emergency surgery that you were unable to request on active screen. Enter name of that surgical procedure.
                  c. Follow up tests and labs for later date and for stat use. Enter those Stat labs that are important but you did not have time to order by the time you reached 2-min screen.
                  - Entering the stat labs on 2-min screen allows the software to know that you have thought about it and ordered it.
                  Remember that on active screen you can order labs and advance clock to get results. But on 2-min screen you can order but can not advance the clock to see results. Though you can not get the results, just by entering them on 2-min screen you can get at-least a partial score.
                  - Enter any follow-up labs for later date using the calendar. These include follow up labs and procedure to monitor efficacy or toxicity of an intervention or a drug that you started on active screen.
                   
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                  steveme

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                    CCS Tip #5
                    Regarding COUNSELING orders and confusion.

                    From source: ( content obtained from another forum)
                    ********** clarifies how much is needed for counseling on 2 min screen.
                    You should not put routine counseling orders in unstable cases and for that matter, in most inpatient cases. For some regular office cases that are in for general check up, you can do routine counseling.
                    If you end up doing routine counseling on 2 min screen, you use up all the time quickly. Archer tells to make use of 2 min screen for setting up follow up monitoring of efficacy and side effects of interventions which are scored - this is why Archer says you must make use 'later" button on 2 min screen to set up monitoring.
                    Do not waste time on routine counseling.
                    Counseling gets scored only if it is "case specific" such as "sexual partner needs Rx" in case of Trichomonas case etc

                    If you counsel the way UWorld orders all routine counseling in the read out cases, you will exhaust all time. What is important is monitoring orders on 2min screen not the routine counseling.
                    Do not forget what Archer says are most highly scored on CCS - DLMTS - DIAGNOSIS, LOCATION, MONITORING, TIMING AND SEQUENCING.
                     
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                    steveme

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                      CCS Tip # 6

                      Approaching 10 min cases soon after vitals are presented:
                      Recognize Shock or Respiratory failure or Altered mental status quickly.
                      Formulate a plan to quickly stabilize vitals. Stabilizing vitals depends quickly finding the likely cause of unstable vitals.

                      In shock there are 4 broad categories:
                      1. OBSTRUCTIVE
                      2. HYPOVOLEMIC
                      3. DISTRIBUTIVE
                      4. CARDIOGENIC
                      For example, obstructive shock : per Dr.Red in **********, find clinical clues and start acting with intervention quickly. You got to minimize the "simulated time" that you take to intervene with life saving orders, otherwise you lose score.
                      Obstructive shock - examples: pneumothorax, cardiac tamponade, , air embolism and piulmonary embolism
                      In cardiac tamponade, you will have pulsus paradoxus, muffled heard sounds and JVD. Once you have shock and those clinical signs , act fast - do Pericardiocentesis based on clinical clues. You get almost 60% score with that action since it is only 10 min case and they are really looking for that immediate life-saving step. Ordering an Echocardiogram before pericardiocentesis is fine. But advancing the clock and waiting for an echocardiogram result even when you have clear clinical exam clues of hemodynamically unstable cardiac tamponade, will cause you to lose score. Waiting for an Echo result to come back eats up simulated time and takes you longer to intervene in a patient crashing with cardiac tamponade.
                       
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                      VCorp

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                        Thanks @steveme for these updates. Our of curiosity, do you believe that the CCS portion can make or break you in terms of your score? I absolutely want to get above a 245 on the exam. Exam isn't until end of August. I'm extremely worried as people say that the best predictor of Step 3 is your CK score, and I did very poorly on it with a score of 213.
                         
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                        steveme

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                          Thanks @steveme for these updates. Our of curiosity, do you believe that the CCS portion can make or break you in terms of your score? I absolutely want to get above a 245 on the exam. Exam isn't until end of August. I'm extremely worried as people say that the best predictor of Step 3 is your CK score, and I did very poorly on it with a score of 213.

                          Hi Vcorp.
                          Thank you. I learn while I post, it is helping me as well :)
                          I do not think step 2ck score is the only predictor for Step 3 score. Step 3 score is dependent on how well you do on CCS also....not just on the MCQs.
                          Your step 2ck does not take in to account how you perform on the Step 3 CCS. In general, higher Step 2ck score indicates you have more deeper clinical knowledge but that alone does not do the trick. There are people with high Step 2CK scores that failed because they did poorly on the CCS. Step 3 CCS is strategic and I think we have ability to improve our score with lots of practice and applying the required strategies.
                          Here is a very convincing analysis why Step 3 CCS performance may make or break Step 3 scores : Archer USMLE BlogWhat predicts USMLE Step 3 performance?
                           
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                          MetroPath

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                            In fact, doing extremely well on CCS with only a borderline performance on MCQs is sufficient to pass Step3! And this is achievable and much easier than achieving an above average performance on the MCQs

                            Ive taken this beast and this is veryyyyyyyyyyyyy true if you are looking to just pass this test.
                             
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                            steveme

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                              In fact, doing extremely well on CCS with only a borderline performance on MCQs is sufficient to pass Step3! And this is achievable and much easier than achieving an above average performance on the MCQs

                              Ive taken this beast and this is veryyyyyyyyyyyyy true if you are looking to just pass this test.

                              Yes, completely agree!
                              Here is a good analysis : Archer USMLE BlogWhat predicts USMLE Step 3 performance?
                               
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                              VCorp

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                                In fact, doing extremely well on CCS with only a borderline performance on MCQs is sufficient to pass Step3! And this is achievable and much easier than achieving an above average performance on the MCQs

                                Ive taken this beast and this is veryyyyyyyyyyyyy true if you are looking to just pass this test.

                                I'd like to get atleast a 250 on this exam. I'm taking it early September to have it back in time for my ERAS application.
                                 

                                copper7

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                                  "Here is a very convincing analysis why Step 3 CCS performance may make or break Step 3 scores : Archer USMLE BlogWhat predicts USMLE Step 3 performance?"
                                  ================================
                                  I like their Conclusions Individualized Step 3 scores provide medical schools with additional means to externally validate their educational programs and to enhance the scope of outcomes assessments for their graduates.
                                  They came to it from: There were significant first-order associations between Step 3 scores and each of USMLE Step 1 and Step 2 scores, third-year clerkships’ grade point average (GPA), Alpha Omega Alpha election, Medical Scientist Training Program graduation, broad-based specialty residency training...
                                  In other words, everything (most) is already preset even before the exam. So, what is the point to take the exam? If you are selected base on your high Step 1 and 2 scores, you do not need any additional test.

                                  I would like to see a study where experienced doctors, NBME board members, PDs takes Step 3 exam. They should be on the top of the game ("gold standard"), right? Can the test measure the reality? This is how you calibrate a test to a gold standard, right? If they fail, it means the test is useless. If they need time and effort to adjust reality, the test is useless. All of them, Step1-3 are just IQ tests.
                                   
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                                  OGY

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                                    CCS is considered very important for passing Step 3. Despite this, most of us do not place enough emphasis on this. There are so many things we do not notice on software because of not knowing or not practicing enough. Often what our mind does not know, our eyes do not see. I am starting this thread hoping to have a dynamic discussion on CCS to keep myself involved and updated. Most strategies posted here are from my own understanding and what I gathered from going through ********** videos and Step 3 online forums.
                                    Please feel free to contribute to this thread.

                                    CCS tip #1
                                    Anything that you manually type in to the blank box is not picked up and scored by software.
                                    1. Diagnosis is not scored
                                    2. Reason for consultation that you type in the box is not scored but you must state reason for consultation by selecting and placing an order

                                    The USMLE Bulletin says we must close the case before the time run out, it means we need to watch the timer all the time. It is distruncing and not scorred after all?
                                     
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                                    OGY

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                                      "Here is a very convincing analysis why Step 3 CCS performance may make or break Step 3 scores : Archer USMLE BlogWhat predicts USMLE Step 3 performance?"
                                      ================================
                                      I like their Conclusions Individualized Step 3 scores provide medical schools with additional means to externally validate their educational programs and to enhance the scope of outcomes assessments for their graduates.
                                      They came to it from: There were significant first-order associations between Step 3 scores and each of USMLE Step 1 and Step 2 scores, third-year clerkships’ grade point average (GPA), Alpha Omega Alpha election, Medical Scientist Training Program graduation, broad-based specialty residency training...
                                      In other words, everything (most) is already preset even before the exam. So, what is the point to take the exam? If you are selected base on your high Step 1 and 2 scores, you do not need any additional test.

                                      I would like to see a study where experienced doctors, NBME board members, PDs takes Step 3 exam. They should be on the top of the game ("gold standard"), right? Can the test measure the reality? This is how you calibrate a test to a gold standard, right? If they fail, it means the test is useless. If they need time and effort to adjust reality, the test is useless. All of them, Step1-3 are just IQ tests.

                                      It is a good point.
                                       
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                                      steveme

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                                        steveme

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                                          The USMLE Bulletin says we must close the case before the time run out, it means we need to watch the timer all the time. It is distruncing and not scorred after all?

                                          Yes- what you type in the diagnosis column is not scored but you still have to close the case. On 2 min screen, after putting essential orders, leave at least 5 seconds for dx, type quickly in Dx column even if it is few letters and close the case.
                                           
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                                          Unty

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                                            Its a 2 minute screen where you add your final orders, counseling orders and followup orders and appointments. It used to be 5 minute screen but now they shortened it to 2 minutes so only add relevant orders as time flies by fast especially with a lagging CCS software at the exam center.
                                             
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                                            steveme

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                                              Hi, just curious. I was listening to the Archer Videos but they keep talking about a "5 minute" ending screen as opposed to what I'm used to from UWorld and all the forums etc. which state this is a "2 minute" window.

                                              What is it on the actual test?

                                              It's all 2 min screens. You should watch Archer 2018 files first and then the old files. There are four video files in Archer 2018 review that are all on new software. The package also has old files for providing exposure to more number of highyield cases
                                               
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                                              bigserve99

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                                                It's all 2 min screens. You should watch Archer 2018 files first and then the old files. There are four video files in Archer 2018 review that are all on new software. The package also has old files for providing exposure to more number of highyield cases

                                                Thanks to both you.

                                                I had some other random questions which any prior takers or persons with knowledge might be able to help with:

                                                1. as far as d/c'ing the inpatient orders if the patient is ready for discharge.... is this something that should be done if the case ends early and it skips to the 2 minute screen? I mean, it's not a big deal, but it takes a lot of time to go through and click on each order and d/c it. Does the USMLE CCS software allow you to highlight multiple orders and d/c at once? Does the scoring take into account all the d/c'ing as necessary?
                                                As a corollary, sometimes these patients come in with meds they had when they came in.... like say hydralizine (PO) or metoprolol PO for BP control. Let's say the case was "hypertensive emergency".... typically in the hospital setting we d/c they're PO meds, and use only IV labetalol let's say, transition them back to PO and then d/c them with follow up for HTN management. So then, during the case do we need to D/C metoprolol and hydrazine and then remember to add it back on the 2 minutes screen?

                                                As a corollary, the UWorld case for this example (hypertensive emergency), makes no mention of adding an ACE-Inhibior or ARB on d/c even though this guy came in with HTN emergency and shows evidence of renal failure on the UA. Wouldn't this be something you guys would do... or would u just schedule a follow up outpatient appointment in a few weeks and have them start it then?

                                                2. Does the time run while reading the initial CC and HPI windows?

                                                3. How do you make follow up APPOINTMENTS on the 2 minute window? Doesn't seem possible.
                                                 

                                                steveme

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                                                  Bigserve99, here are some answers to your questions. My primary reference source for these answers is ********** course.

                                                  1. This is an extremely important point. Archer says some cases of CCS failure are due to premature discontinuation of inpatient orders anticipating discharge. Discontinuation of orders in anticipation of discharge should only be done when “simulated time” is appropriate for discharge and discharge criteria are met.

                                                  Sometimes, case ends very soon. For example, Pneumothorax case on Primum USMLE Software ends in 2 hours of simulated time. So when you reach 2 min screen, you are at around 2 hours of simulated time after you placed chest tube and subsequently would have obtained a follow-up chest x-ray. So if you discontinue the chest tube at this point, the software would read it as you have discontinued chest tube 2 hours after placing it while the patient is still in the hospital within 24 hours after admission. The criteria for discontinuing chest tube is not reaching the 2 minute screen but making sure that the air leak had stopped. Once the air leak stops, chest tube can come out. For this to happen, you need to wait at least a day and advance clock 24 hours later but the software typically is not looking for all these and will end this case at 2 hours of simulated time. So anyone who attempts to discontinue the chest tube at this point will be heavily penalized and some people have lost the cases because of these actions. Unfortunately, Uworld CCS which most of us use does not explain all this properly. So please do realize that reaching the 2 minute screen is not an automatic indication to discontinue the orders. Discontinuation of the orders should be dependent on the simulated time criteria as well as may discharge/discontinuation criteria.



                                                  I will give another example: A patient with pneumonia and fever, age greater than 70 is admitted to hospital and he was started on IV antibiotics. He is not swallowing properly, has nausea and vomiting. On day 1, as you advance the clock, 2 min screen may appear. Now. do not discontinue IV antibiotics and switch over to oral antibiotics yet because you are still on DAY 1 simulated time. The software has not alerted you that the patient started to take things orally again. So it is important to pay attention to all of these. I think your question is very important, several examples like these shown in ********** and cleared up my confusion with this.


                                                  2. Yes, real time runs always. You have only 20 mins for long cases and it keeps running when you read CC/ HPI etc. You got to be fast. You got to be faster in 10 min cases.

                                                  Remember, “simulated/ patient time” does not run when you do not advance the clock but real time keeps running as you wait and stare at the screen.


                                                  3. Best way to make follow up appointments on 2min screen is to order necessary follow up tests at a later date. When you choose “later” option, you are given a calendar option from where you can choose the date of test and follow-up. For example; you have a patient with STEMI and you are discharging, order 2D echo in 3 months while on 2min screen. Order Cardiac rehab later. Order Lipid panel in 3months if you started Statin.

                                                  I hope this answered your questions. If not, please ask and will clarify. Please excuse any typos.
                                                   

                                                  VCorp

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                                                    Bigserve99, here are some answers to your questions. My primary reference source for these answers is ********** course.


                                                    I hope this answered your questions. If not, please ask and will clarify. Please excuse any typos.

                                                    Amazing answer, but this is super confusing. I'm actually super worried about what to do when the 2-minute window comes up. I need to master down which meds to switch from IV to oral.

                                                    When you get to the first screen of putting in your orders, how are you normally advancing the clock? I just click on "call me when orders are in".
                                                     

                                                    steveme

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                                                      Vcorp, I was in the same situation ..but it can get very easy once you start practicing the cases. Like I mentioned above, reaching 2-min screen is not an immediate criterion to switch IV to PO. Discharge criteria must be met. If you are confused regarding this, I suggest you watch ********** workshops and see how cases are done on the exam software, how discharge orders are placed and the rationale for the way it was done. All of it is clearly explained there. You get to know how to navigate and how software responds.
                                                      Have you practiced on the official exam software at www.usmle.org ? UWorld can get confusing sometimes with their sequencing.

                                                      With regard to your second question, choosing next available result or to a time period of your choice would be the best way to advance the clock. "call me as needed" is also fine but it may lead to too much time advancement in future before next update comes in. Still, after every update of results or status, you are given an option "stop the clock". For example, let us say you chose "call me as needed" but next result popped up showing "glucose 30". Options given to you below the result are "stop the clock" or "continue". This time point and your action is crucial.
                                                      Accidentally, if you hit "continue", your simulated time may jump in to future point leading to loss of precious opportunity to address critical hypoglycemia right away. This can lead to big loss of score. You need to choose STOP THE CLOCK and then give IV Dextrose right away.
                                                      This sequencing of actions is all clearly shown in **********.
                                                      If you feel that particular result needs to be addressed right away, you need to stop the clock because advancing can lead to losing simulated time and penalty
                                                       

                                                      Unty

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                                                        Vcorp, I was in the same situation ..but it can get very easy once you start practicing the cases. Like I mentioned above, reaching 2-min screen is not an immediate criterion to switch IV to PO. Discharge criteria must be met. If you are confused regarding this, I suggest you watch ********** workshops and see how cases are done on the exam software, how discharge orders are placed and the rationale for the way it was done. All of it is clearly explained there. You get to know how to navigate and how software responds.
                                                        Have you practiced on the official exam software at www.usmle.org ? UWorld can get confusing sometimes with their sequencing.

                                                        With regard to your second question, choosing next available result or to a time period of your choice would be the best way to advance the clock. "call me as needed" is also fine but it may lead to too much time advancement in future before next update comes in. Still, after every update of results or status, you are given an option "stop the clock". For example, let us say you chose "call me as needed" but next result popped up showing "glucose 30". Options given to you below the result are "stop the clock" or "continue". This time point and your action is crucial.
                                                        Accidentally, if you hit "continue", your simulated time may jump in to future point leading to loss of precious opportunity to address critical hypoglycemia right away. This can lead to big loss of score. You need to choose STOP THE CLOCK and then give IV Dextrose right away.
                                                        This sequencing of actions is all clearly shown in **********.
                                                        If you feel that particular result needs to be addressed right away, you need to stop the clock because advancing can lead to losing simulated time and penalty

                                                        I never switched IV to PO in any of my cases and I almost had a score performance to the far right. (Three stars away from hitting the higher performance side)

                                                        Once you've done everything you need to, cases will end. So most of the time, you don't need to change IV to PO because patients haven't been in the hospital long enough to do so.
                                                         
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                                                        steveme

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                                                          I never switched IV to PO in any of my cases and I almost had a score performance to the far right. (Three stars away from hitting the higher performance side)

                                                          Once you've done everything you need to, cases will end. So most of the time, you don't need to change IV to PO because patients haven't been in the hospital long enough to do so.

                                                          Absolutely correct!
                                                           

                                                          steveme

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                                                            Also, I have seen people worry about cases ending early. Cases ending early does not matter as long as you have monitoring orders put in place since the beginning of the case and those vitals/ lab monitoring were giving updates showing improvement with your interventions. Remember to place 2 min monitoring orders using "later" date if you have crucial orders left behind but reached 2mins too early.
                                                            ********** says monitoring is highly scored on CCS and that is the reason software particularly has "later" option on 2 min screen.
                                                             
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                                                            steveme

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                                                              CCS Tip #7
                                                              ( Source : content obtained from ********** with permission)

                                                              Monitoring blood pressure via. arterial line.
                                                              Arterial lines are indicated when you want to accurately measure the mean arterial pressure to titrate the rate of continuous infusions of vasopressors or antihypertensives. This is more accurate than non-invasive BP measurements. This is invasive procedure so should only be ordered when indicated. A-line is also done when you want frequent blood gas analysis (ABG) in acidosis or respiratory failure patients.

                                                              Placing A-line is scored on exam when indicated. This is a crucial step to titrate vasoactive drugs
                                                              Place an order for "arterial catheter" in cases of
                                                              1. Shock requiring vasopressors to sustain Blood Pressure and maintain MAP > 65. Eg: Septic shock not responding to IV hydration alone and is on pressors like norepinephrine or dopamine. You need to place A-line to adjust the flow rate of these drugs to target accurate MAP.
                                                              2. Hypertensive emergencies requiring continuous infusions of antihypertensive drugs eg: Sodium nitroprusside in hypertensive emergency/ stroke from hypertensive emergency where it is critical to maintain a target BP accurately
                                                               

                                                              steveme

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                                                                CCS Tip #8

                                                                Stopping the Clock ( Reference: ********** )
                                                                1.
                                                                Stopping the clock is crucial when necessary to address test results immediately. This can be applied to both ER and office settings.
                                                                2. Most people get confused whether to continue to advance the clock to certain point in the future when test results start popping up based on the designated report times for each order you have placed at the beginning of the case.
                                                                3. Remember each time a test result pops up while you advance the clock, the first thing that you should think of is whether this test result needs to be addressed STAT or can it wait?
                                                                For example: If a patient came with altered mental status to ER --> you placed some initial orders including CBC, CBC, Glucose by glucometer, alcohol level, UDS.
                                                                Let's say you did a quick physical and advanced the clock by an hour. As the time moves, blood glucose result may pop up when it's designated report time is reached. It may show 20mg% at 10 min of simulated time. Now, most users may not pay attention to clock and may advance the clock further. This may cause you lose most of the case.
                                                                In this scenario, it is important to stop the clock --> go to order sheet and put in the orders for dextrose Iv and other stabiliing orders for hypoglycemic coma. Advancing clock without addressing life threatening results immediately is one reason why some lose the full 10 min case in the ER.

                                                                This can happen in Office setting as well after you send the patient home with a reappointment in a week or so. Make sure you stop clock and address if an important test result comes back before the reappointment time. Also, remember that each time you stop the clock, previous appointment will be cancelled by the software. So you should reschedule the appointment every-time you stop the clock.
                                                                 

                                                                RedSoxSuck

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                                                                  Yes, completely agree!
                                                                  Here is a good analysis : Archer USMLE BlogWhat predicts USMLE Step 3 performance?


                                                                  I always thought that borderline / average performance on MCQs with superior performance on CCS means you will pass. Following attachment illustrates superior or high CCS performance along with mediocre MCQs = Fail.

                                                                  Thoughts?

                                                                  IMG_9124.jpg IMG_9125.jpg
                                                                   

                                                                  RedSoxSuck

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                                                                    CCS Tip #8

                                                                    Stopping the Clock ( Reference: ********** )
                                                                    1.
                                                                    Stopping the clock is crucial when necessary to address test results immediately. This can be applied to both ER and office settings.
                                                                    2. Most people get confused whether to continue to advance the clock to certain point in the future when test results start popping up based on the designated report times for each order you have placed at the beginning of the case.
                                                                    3. Remember each time a test result pops up while you advance the clock, the first thing that you should think of is whether this test result needs to be addressed STAT or can it wait?
                                                                    For example: If a patient came with altered mental status to ER --> you placed some initial orders including CBC, CBC, Glucose by glucometer, alcohol level, UDS.
                                                                    Let's say you did a quick physical and advanced the clock by an hour. As the time moves, blood glucose result may pop up when it's designated report time is reached. It may show 20mg% at 10 min of simulated time. Now, most users may not pay attention to clock and may advance the clock further. This may cause you lose most of the case.
                                                                    In this scenario, it is important to stop the clock --> go to order sheet and put in the orders for dextrose Iv and other stabiliing orders for hypoglycemic coma. Advancing clock without addressing life threatening results immediately is one reason why some lose the full 10 min case in the ER.

                                                                    This can happen in Office setting as well after you send the patient home with a reappointment in a week or so. Make sure you stop clock and address if an important test result comes back before the reappointment time. Also, remember that each time you stop the clock, previous appointment will be cancelled by the software. So you should reschedule the appointment every-time you stop the clock.


                                                                    Regarding stopping the clock to address abnormal labs, do i need to bring the patient back to the office to address the abnormal labs? Or can I leave the patient at home, address the labs and then reschedule the appointment?


                                                                    2 minute screen:


                                                                    I think typing "counsel" is good because then you can select the following from the pop up screen [counsel the patient, medication compliance/adverse reactions, no smoking, no alcohol, no illicit drugs"

                                                                    - Also typing Vaccines and then selecting age appropriate such as "influenza, varicella (>60 yo), pneumococcal vaccine"

                                                                    Question regarding the vaccines:

                                                                    Do I need to choose administer now OR at a later date? Generally, I select "later" and quickly scroll down and just pick a date works?


                                                                    Age appropriate screening:


                                                                    - Colonoscopy, pap, mammo , dexa scan" I would assume that these should be done at a later date (i.e. few weeks down the line)?

                                                                    Entering vaccines and age appropriate screening should be done for outpatient cases but what about 8+2 minute pneumothorax case? I would assume that the patient is stable once the 2 minute screen pops up so entering these should not be a problem. Obviously, you do not want to council and or do anything to agitate the patient as they are being stabilized.

                                                                    Thoughts?
                                                                     

                                                                    steveme

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                                                                      I think doing 100 ccs cases is worth it. They grade you so can actually see your score. It helps to know where you lose points.

                                                                      Unfortunately, this software's grading is not accurate, very misleading because it gives extra weight to areas that don't matter much and the strategies are not right. There's no guidance with exact guideline based assessment in sequencing the tests or accurate score allotment to the timing and tests that matter. No software comes close to the actual primum based CCS exam software at usmle.org . If I were to choose between ccscases site and uworld , I would go with UWorld which is more accurate. For actual strategy and sequencing/ orders, guidelines, I would go with **********.
                                                                       
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                                                                      RedSoxSuck

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                                                                        Unfortunately, this software's grading is not accurate, very misleading because it gives extra weight to areas that don't matter much and the strategies are not right. There's no guidance with exact guideline based assessment in sequencing the tests or accurate score allotment to the timing and tests that matter. No software comes close to the actual primum based CCS exam software at usmle.org . If I were to choose between (edited by moderator--posting of links to for-profit resources is not allowed) , I would go with UWorld which is more accurate. For actual strategy and sequencing/ orders, guidelines, I would go with (edited by moderator--posting of links to for-profit resources is not allowed).
                                                                        I agree with you. I was just saying that these cases are good for extra practice. They shouldn't replace UW. And I am not affiliated with them in any shape or form. Just extra practice. That's all.
                                                                         
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                                                                        steveme

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                                                                          I agree with you. I was just saying that these cases are good for extra practice. They shouldn't replace UW. And I am not affiliated with them in any shape or form. Just extra practice. That's all.

                                                                          Thank you.....Yes but that particular software can be a bit misguiding with guidelines and scoring. All the best for your exam
                                                                           

                                                                          steveme

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                                                                            I have seen a few threads on SDN wondering if typing the final diagnosis is needed and if it is scored. I reiterate that Final diagnosis is not needed for scoring. In ********** also, the instructor explains reasons why it is not even scored. It is not in the algorithm of CCS software to detect your typos in that column and to match with software's artificial intelligence. What the software scores is how your patient was managed based on the time, efficiency and safety. If your patient was improving by the time case ended, stabilizing orders were placed, monitoring orders were in place, you should get most of the score. Do not forget monitoring orders ( mentioned above) which are critical in getting a lot of score. Monitoring orders is also one area where UWorld software falls short of addressing and explaining how they work for specific cases using the calendar option.
                                                                             
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                                                                            witzelsucht

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                                                                              few questions, 10 days til exam:

                                                                              how bad can you do on CCS and pass if you are looking at a solid MCQ score?

                                                                              assuming you hit the critical actions (needle decompression, ct angio for dissection, mag for eclampsia), how much does the disposition stuff matter? if you leave them in the ED or ward, don't de-escalate orders, etc. does that even really matter? the office followup stuff is also bothering me. ive been bringing the depressed people back for like q1 week office visits. does that negatively impact your score or as long as you have some followup its ok? another thing on the depression case - i sent a CBC/vit D/tsh, cbc was normal so i didnt bother with B12 level. minus points? uworld seems to think so. im an ED resident so this stuff is all new. what about stat vs routine labs? didnt do a boob exam on depressed lady, that can't effect your score much, right? it seems like the scoring is mostly based on critical actions not inefficiency...
                                                                               

                                                                              steveme

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                                                                                few questions, 10 days til exam:

                                                                                how bad can you do on CCS and pass if you are looking at a solid MCQ score?

                                                                                assuming you hit the critical actions (needle decompression, ct angio for dissection, mag for eclampsia), how much does the disposition stuff matter? if you leave them in the ED or ward, don't de-escalate orders, etc. does that even really matter? the office followup stuff is also bothering me. ive been bringing the depressed people back for like q1 week office visits. does that negatively impact your score or as long as you have some followup its ok? another thing on the depression case - i sent a CBC/vit D/tsh, cbc was normal so i didnt bother with B12 level. minus points? uworld seems to think so. im an ED resident so this stuff is all new. what about stat vs routine labs? didnt do a boob exam on depressed lady, that can't effect your score much, right? it seems like the scoring is mostly based on critical actions not inefficiency...


                                                                                Regarding your question about the possibility of passing despite doing very poorly on CCS, it is bit hard to answer that question with certainty. It really depends on how well you performed on MCQs to compensate for the CCS loss. Most people do it other way round. They do really well on CCS to compensate for poor MCQ performance.
                                                                                It appears like if the CCS performance is really low, the burden on MCQs increases heavily.
                                                                                One really good analysis from ********** review using their students' previous score reports can be found at their blog.
                                                                                This analysis indicates CCS can give a meaningful boost to the score. ( In the video, note an interesting score report where a person performed extremely poorly on CCS but did above average on MCQs and still failed).

                                                                                From what you mentioned, you have done fairly well. Monitoring is crucial and fetches you score. It appears like you have had thorough monitoring orders in place. Best wishes to you!
                                                                                 
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                                                                                witzelsucht

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                                                                                  few questions, 10 days til exam:

                                                                                  how bad can you do on CCS and pass if you are looking at a solid MCQ score?

                                                                                  assuming you hit the critical actions (needle decompression, ct angio for dissection, mag for eclampsia), how much does the disposition stuff matter? if you leave them in the ED or ward, don't de-escalate orders, etc. does that even really matter? the office followup stuff is also bothering me. ive been bringing the depressed people back for like q1 week office visits. does that negatively impact your score or as long as you have some followup its ok? another thing on the depression case - i sent a CBC/vit D/tsh, cbc was normal so i didnt bother with B12 level. minus points? uworld seems to think so. im an ED resident so this stuff is all new. what about stat vs routine labs? didnt do a boob exam on depressed lady, that can't effect your score much, right? it seems like the scoring is mostly based on critical actions not inefficiency...

                                                                                  to answer my own questions - unlike the UW answer choices, on the real exam there does not seem to ever be an option to de-escalate IV orders to PO, follow up in office. the office cases stay in office and the hospital cases stay in the hospital. its very obvious when the "cure" has been administered and the case ends.
                                                                                   
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