Step III and the psych resident

[Doctor Bagel]

So feeling a little neurotic (like usual) and wanted to ask how other psych residents approach Step III. I guess mainly I'm looking for reassurance since I'm taking the test this week, but study tips for psych residents taking the test would be awesome. The step III forum seems to be filled with spammers and people with lots of extenuating circumstances, making it not the best place for practical advice.

Is it just me, or do the practice questions for Step III seem pretty challenging? I haven't done any peds, surgery or ob/gyn rotations since medical school, and I've never done an ICU rotation. HIV medicine is another blank area for me because we did all our inpatient medicine at the VA, treating sweet old dudes with CHF and NSTEMIs.

So far I've done all of USMLEWorld and am averaging an OK amount correct. I've also done the CCS questions. I can always make the right diagnosis, but there's always some workup issue that I miss. I generally do well on standardized tests and don't have much anxiety around them, but Step III is freaking me out for some reason. I guess it would be really embarrassing to fail since it's supposedly so easy.

How did you study? Was it enough? Should psych residents put forth effort to do extra studying due to our limited general medical education in residency?

---

Members don't see this ad.

 

[nitemagi]

USMLE World and first aid. For me it was intern year, medicine was fresh, so it felt fairly easy.

I wouldn't overthink it. Like any standardized test, figure out your weak areas that're high yield and focus your energy and time there.

 

[Doctor Bagel]

USMLE World and first aid. For me it was intern year, medicine was fresh, so it felt fairly easy.

I wouldn't overthink it. Like any standardized test, figure out your weak areas that're high yield and focus your energy and time there.

I bought Master the Boards, but I haven't been able to make much progress on it. It's too detailed for it to be an effective studying tool for me. Maybe I should have tried First Aid. I usually learn best by doing questions anyway, so that's been my primary focus. We'll see if that works in a few weeks.

Last night of studying. I've got my compulsive test rituals, which include eating pasta, packing my lunch, making gatorade and 100% not studying the night before a standardized test.

 

[nitemagi]

The worst that happens is you have to take it again...

 

[Doctor Bagel]

The worst that happens is you have to take it again...

It's just $730, right? From my studying, I'm thinking psych residents should take the test earlier in their residency. We spend most of our time dealing with pretty basic general medicine and pretty complex psych medicine, which doesn't set you up well for this test, from what I've seen. I normally don't freak out about standardized tests, but this one is making me nervous.

BTW, I came across a wrong psych answer re: 2nd generation antipsychotics. According to UW answer, 2nd generation antipsychotics have less negative symptoms than 1st generation antipsychotics. I was taught this in medical school, but my understanding is that there's no strong data to support this.

 

[TexasPhysician]

USMLE World and first aid. For me it was intern year, medicine was fresh, so it felt fairly easy.

I wouldn't overthink it. Like any standardized test, figure out your weak areas that're high yield and focus your energy and time there.

USMLEWorld and First Aid are money!

 

[Doctor Bagel]

USMLEWorld and First Aid are money!

Hmm, so First Aid. I'll keep that in mind if I have to take the test again. I'm not a fan of Master the Boards.

 

[nitemagi]

BTW, I came across a wrong psych answer re: 2nd generation antipsychotics. According to UW answer, 2nd generation antipsychotics have less negative symptoms than 1st generation antipsychotics. I was taught this in medical school, but my understanding is that there's no strong data to support this.

This myth is still floating around all over. It's in the MGH boards book too (though to be fair that hasn't been revised since 2004).

 

[Encephalopathy]

BTW, I came across a wrong psych answer re: 2nd generation antipsychotics. According to UW answer, 2nd generation antipsychotics have less negative symptoms than 1st generation antipsychotics. I was taught this in medical school, but my understanding is that there's no strong data to support this.

I think UW is theoretically correct, though not sure if it's been borne out clinically. Atypicals haven't been shown to improve negative sx, but relative to typicals the prevailing wisdom is that 5HT2 antagonism "releases the brake" on dopamine in the mesocortical pathway, making them less "blunting" than typicals.

 

[nitemagi]

I think UW is theoretically correct, though not sure if it's been borne out clinically. Atypicals haven't been shown to improve negative sx, but relative to typicals the prevailing wisdom is that 5HT2 antagonism "releases the brake" on dopamine in the mesocortical pathway, making them less "blunting" than typicals.

Yes. contrasted with the mesolimbic path for positive sx's. But it's this theoretical basis without clinical evidence that is the origin of a lot of critique of the Stahl reductionistic "cartoon" explanation of mental illness.

 

[koc123]

Granted I took Step 3 years ago. I was an obgyn resident who did 2 months of IM and 2 months of ER and the rest of months were ob. I passed step 3 without studying at all. I think you will be fine.

 

[Doctor Bagel]

Granted I took Step 3 years ago. I was an obgyn resident who did 2 months of IM and 2 months of ER and the rest of months were ob. I passed step 3 without studying at all. I think you will be fine.

This post makes me happy! I hope you're right.

 

[CaMD]

I took it in the middle of intern year, and while I know it's too late for you, I would strongly encourage most psych interns to get it out of the way. You'll only get further removed from medicine/surg/etc as time goes on.

All I did was USMLE World and I got a score very similar to how I did on Steps 1 & 2, despite much less preparation.

I would recommend figuring out how the buttons work on the weird clinical scenarios part. They weren't difficult per se, but the system is a but wack, so I'd practice that.

 

[Doctor Bagel]

I took it in the middle of intern year, and while I know it's too late for you, I would strongly encourage most psych interns to get it out of the way. You'll only get further removed from medicine/surg/etc as time goes on.

All I did was USMLE World and I got a score very similar to how I did on Steps 1 & 2, despite much less preparation.

I would recommend figuring out how the buttons work on the weird clinical scenarios part. They weren't difficult per se, but the system is a but wack, so I'd practice that.

I definitely agree that taking it earlier is better. I put it off partially due to laziness and partially due to scheduling conflicts (took ed leave for APA in May and vacation in June, and also didn't finish medicine and ED rotations which I thought would be helpful until the end of intern year). We'll see how stuff works out tomorrow, but I think even if you have to delay it, doing it early in 2nd year is better than continuing to put it off. It'll be nice to not have it hanging over my head anymore.

 

[billypilgrim37]

My Step scores went like this:

Step 1: X.
Step 2: X-9.
Step 3: X+9.

Go figure. I get really dumb for step 2 and really smart for step 3. I'm pretty sure that's a whole lot of opposite compared to most people.

 

[Doctor Bagel]

My Step scores went like this:

Step 1: X.
Step 2: X-9.
Step 3: X+9.

Go figure. I get really dumb for step 2 and really smart for step 3. I'm pretty sure that's a whole lot of opposite compared to most people.

So far, I've been:

Step 1: X
Step 2: X - 7
My prediction for Step 3: X-40, which I guess would be fine.

I just keep getting less smart.

 

[whopper]

I took this exam about 3.5 years ago but here is what I remember.

USMLEWorld was far better than Kaplan questions. Kaplan's questions are accurate to the examination, but are on the far easier side of what to expect. I was getting about 80% of the Kaplan questions right but my USMLE score, while passing, was not indicative of that performance. I forgot what the score was, but people told me as long as you score a certain amount on USMLEWorld, expect to pass the real exam.

The other thing is the second portion of the exam, the simulation, is very easy to screw up if you don't understand how it works. I recommend you get the thing down straight before you take the real one. To do that, practice all the ones they have available on the simulation.

 

[jamesearlejones]

that test sucked. i would definitely take studying for it seriously (which it sounds like you're doing). i literally followed the "2 months, 2 weeks, #2 pencil strategy" (ie, not studying at all) and i barely passed, after having done really well on steps 1 and 2. i can't offer you any specific advice on which materials are most helpful (since i didn't study) and i'm not trying to freak you out--just letting you know it's good that you're taking it seriously and i think it will help immensely that you're actually preparing for it.

 

[Doctor Bagel]

that test sucked. i would definitely take studying for it seriously (which it sounds like you're doing). i literally followed the "2 months, 2 weeks, #2 pencil strategy" (ie, not studying at all) and i barely passed, after having done really well on steps 1 and 2. i can't offer you any specific advice on which materials are most helpful (since i didn't study) and i'm not trying to freak you out--just letting you know it's good that you're taking it seriously and i think it will help immensely that you're actually preparing for it.

First day was not so hot. I could usually get it down between two answers, but there were lots of time where I couldn't go any farther than that. It is a harder test than it's made out to be. Well, I just need to pass.

 

[bounds]

I know this is late for you now but might helpful for others preparing for Step 3 CCS cases with some modifications


LOGICAL APPROACH TO ANY CCS CASE :
______________________________________


Take a deep breath and select ‘Start Case’ button to begin.

You will see the case introduction. Wait! Note on the erasable board:

Setting
Age of the patient
Race of the Patient
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.

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.


Patient education / Counseling options :


Every adult person - Drive with seat belt, Exercise program, No illegal drug use.

Every person taking long-term medications - Medication compliance, Side effects of medication.

Every person who takes alcohol - Limit or stop alcohol intake.

Every person who smokes - Smoking cessation.

Every person of reproductive capacity - Safe sex techniques.

Every person with long-term conditions, life-threatening allergies, chronic illnesses - Medic Alert Bracelet.


Female requesting contraception or practicing unsafe sex - Birth control, Contraception, Safe sex techniques.

Cancer case - Cancer diagnosis.

Asthmatic - Asthma care, medication compliance.

Terminal case - Advance Directive (Family), Advance Directive (Patient) and Living will.

Every post-operative case - Deep breathing and coughing

Diabetic - Diabetic foot care, Home glucose monitoring, Diet.

Learning disorder kid - Educational remediation.

Osteoporosis - Estrogen replacement therapy.

HIV case - HIV support group, safe sex techniques.

Hypothyroidism or endocrine case - Hormone replacement therapy.

Lactose intolerance - Limit cow's milk intake, Diet.

GI bleeding, peptic ulcer case - No aspirin, Sit upright after meals.

Old age, epileptic, vision defects, narcolepsy - No driving.

Anxiety case - Relaxation techniques, Rebreathing into a paper bag.

Violent psychotic case - Restraining order.

Spousal Abuse - Safety plan.

IV drug use - No illegal drug use, SBE prophylaxis, Safe sex techniques, Stop alcohol, Smoking cessation.

Pelvic surgery - No intercourse.

STD - Safe sex techniques, Sexual partner needs treatment.

Depression - Suicide contract.


Routine screening : Schedule appropriate screening tests as per age. Type the relevant test and schedule.

Immunizations : For Pediatrics and Geriatrics as relevant. Type ‘Vaccine’, choose and schedule.

At the end of the 5 minutes:

Type the Final Diagnosis.

 

[bounds]

I don't know whu Musa was but these tips were a life saver review for Step 3, both the mcqs and ccs.



MUSA'S GOLDEN RULES FOR THE STEP3 CCS
__________________________________________

1. If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel.
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
Musa's CCS Golden Rules - Part Deux

31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with IV phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test

Musa's CCS Golden Rules - The Trilogy

51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Alcohol
Tobacco
Exercise
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead pain assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin

 

[jamesearlejones]

First day was not so hot. I could usually get it down between two answers, but there were lots of time where I couldn't go any farther than that. It is a harder test than it's made out to be. Well, I just need to pass.

that's one thing i should have included in my post yesterday: don't let how you feel you did on day 1 affect your day 2 performance. in football, they talk about cornerbacks having a "short memory," meaning that if a cb gets beaten for a long pass play or touchdown, he should try to forget about it because one bad play isn't the end of the world, but if he lets it affect his performance for the rest of the game, the outcome could be bad. for one thing, the questions on day 2 might be totally different and more conducive to your knowledge set. for another, the second half of day 2 really isn't bad. i think most interns at any reputable program should feel pretty comfortable with management in the types of cases they have. i actually kind of enjoyed that part of the test, because it seemed like it was testing me on things i actually knew and did as an intern--as opposed to the ridiculous minutia that was contained in the mcq section.

 

[Doctor Bagel]

Update -- passed! I had about 30 point score drop from previous steps, but that's totally fine. The CCS part did work out well for me, and I agree -- that's an easier part to master when studying. With the MCQ stuff, there's just so much information to know, and our training doesn't help us a lot with it. If I had not studied at all, I think failure would have been a possibility, so don't entirely blow this test off.

My recommendations for psych residents now --

1. try to take this after you've done most of your medicine months because they do help
2. take it earlier if you can. I feel so relieved having this off my back.
3. you're likely to pass, but you probably should do some studying. That #2 pencil stuff might work for FM, EM or medicine folks, but it's not a good idea for us.
4. UW still pretty good
5. UW cases are helpful
6. MTB gets a thumbs down from me
7. FA apparently gets a thumbs up from some of the previous posters