Key points: 1. Timing (1:01) Real time = the actual time/real world time, which is 10-20 min. Simulated time = hypothetical time, which can last from hours to days to weeks. 2. What to look for in case's introduction (2:18) Age Gender Allergies Main HPI points Screening (vaccinations, pap smear, colonoscopy, etc) 3. Physical exam (3:45) Complete physical exam --> if patient is stable or in the office Focused physical exam --> if patient is unstable or in the ED; you can always do a complete PE later in the case after putting in emergency orders! 4. Disposition (4:35) Where do you want the patient to be? Options: home, ED, admit to inpatient, admit to ICU. 5. Emergency orders (5:55) MAVOCCF, which stands for: Morphine Acc (gives you IV access and glucose accucheck) Vitals check Oxygen/oximeter Cardiac monitor C-spine Fluids (normal saline) 6. Routine orders (6:51) CCCMP CUAEH LLUSCENT stands for: CBC, CMP, Creatine phosphokinase, Magnesium, Phosphate Chest x-ray/other x-rays, Ultrasounds, Abg, Ecg/other cardiac tests, Hcg Lactate, Lft/pt/ptt/inr, Urinalysis/culture/toxicology, Stool culture/pH/ova/etc, Culture (blood), Esr/crp, Neuro checks, Tsh 7. You should land on a diagnosis by this point and thus, a treament (9:09) 8. Case might finish early if you have managed the patient correctly (9:27) 9. Once the case finishes, you have 2 minutes at the end to put in last minute- orders (10:00). These can be pap smears, colonoscopies, vaccinations, counseling the patient on various topics. SITPM (vaccines) CPM (screening tests) ISSSAD (counseling) Shingles Influenza Tetanus Pneumococcal Meningococcal Colonoscopy (50-75 yrs, every 10 years) Pap smear (21-65 yrs, every 3 years) Mammography (50-75 yrs, every 2 years) Instruct Smoking cessation Safe sex Seatbelt Alcohol abstention Disease specific (diabetes, medication side effects, etc)
Here is a summary of the entire first part of the video (some of this is abbreviated so hopefully it makes sense, but you can watch and read along) CCS Cases Things to look for initially (brief skim of H&P) - write these on scratch sheet 1. Age 2. Gender 3. Allergies 4. Brief skim of hx 5. Screening/vaccines/social hx (smoke, drink, drugs, sexual hx) **skimming hx - buzzwords (they don’t want to trick you, dx is sometimes very very obvious) ex: RUQ pain exacerbated by fatty foods - gallstones They want to see if you can put in orders correctly, in correct order, and rule out other scary things (i.e ACS, pancreatitis etc) VS Exam: 1. If pt stable (i.e. in clinic and HDS) - complete physical (especially hitting the things they present with) 2. If pt unstable - not doing complete PE, wastes “simulated” time, need to “act fast” and do a focused PE Disposition - Where do you want the patient to be? 1. Home 2. ED 3. Admit 4. ICU STAT orders - Do you want to place any emergency orders? Mnemonic - MAVOCC + F (not all needed, but reminder of some HY examples) 1. Morphine 2. ACC (gives you IV access and glucose accuchecks) 3. Vitals check 4. Oxygen/oximeter 5. Cardiac monitor 6. C-spine 7. Fluids (NS) Orders (mnemonic) - tailor these tests to your ddx, don’t order all every time for every patient CCCMP CUAEH LLUSCENT 1. CBC 2. CMP 3. Creatine phosphokinase (CPK/CK) 4. Magnesium 5. Phosphate 1. CXR (or any XR) 2. US 3. ABG 4. ECG (other cardiac tests - echo, troponins) 5. B-HCG (repro age like case will end early and you have 2 minutes at the end to put in extra orders **refer back to scratch paper for quick reference for these below 1. Screening tests - i.e. colonoscopy, Pap smear, mammography 2. Vaccines - shingles, tetanus, pneumococcal 3. Counseling patient - i.e. smoking/drinking/drug cessation, medications, compliance, side effects, safe sex (if STI case), seat belt SITPM CPM ISSSAD SITPM Vax - based on case, age, gender etc 1. Shingles - zoster max - >50 yo, 2 dose series, now then in 2-6 mo 2. Influenza/COVID - fall/winter season (RSV >60 yo) 3. Tetanus - q10years 4. Pneumococcal >65 (or susceptible to encapsulated organisms) 5. Meningococcal - 2-dose at 11-12 yo and 16 yo CPM Screening 1. Colonoscopy - 45-75 yo (q10years if no abn) 2. Pap smear - (21-29 yo) q3yr w/ cervical cyto alone - (30-65) q3yr w/ cervical cyto alone, q5yr w/ high-risk HPV testing alone, or q5yr w/ hrHPV w/ cyto (co-testing) - Chlamydia/gonorrhea - all sexually active women 25 yo at increased risk for infection 3. Mammography - 50-74 yo - biennial screening ISSSAD Instructing patient - when you type “instruct” into order search, gives you lots of options 1. Instruct 2. Smoking 3. Safe sex 4. Seatbelt 5. Alcohol abstention 6. Disease specific instructions
Super Helpful. Instead of trying to memorize those terrible acronyms, I changed a few. Emergent orders : FAV-MOCCA Workup orders: LUNCHMEATS 4CLUE-P Admit/Treatment orders: CICADA FLAB Closing orders: STIMP shots and CP SADISMS The admit/treatment one I made up: Consult, Insulin, Counsel meds, Abx, Diet, Acid, Fever/pain, Laxative, Activity, Blood (T/S/Transfuse)
I do a targeted exam initially to save time in case there is anything we need to urgently act on. The second is to complete the remainder of the exam to be thorough and not miss anything.
Glad you enjoyed the video! No, the real exam does not tell you what you did right or wrong. In fact, no one knows how the real exam grades your performance. I do think ccscases does a good job of giving feedback and simulating the test taking environment even though it may not necessarily be exactly like the real deal’s scoring style.
Thank you so much for the video. It's really helpful! I don't think you need prophylactic cefazolin on the cholecystitis case as you already started therapeutic piperacillin-tazobactam. Thanks again!
I have an issue with the re-evaluate case, can you please explain how to use the "on" "in" and the others to really maximize time, I hope you see this, thank you for the video also!
I think you’re referring to when you click on the clock and run the time forward. If this is what you mean, I usually click “next available result” because it saves me time from typing exactly how far ahead I want to go. On refers to a certain time you want to go forward to; for example, if it’s 10:15 and you want to skip to 10:45. You would just write “10:45”. In refers to how much you want to skip ahead, using the same example, to skip ahead 30 minutes, you would write “30”. I don’t like to use these because you have to check exactly how far you want to skip ahead and to check you have to click around a lot which will cost you some time (especially with input delay).
@Khalemedic Thank you so much, just saw this! Do you have any websites where I could purchase materials for you just to gain more knowledge? Really appreciate you!
From my experience, it can sometimes lead to the case finishing without completing everything. If you avoid using that option, the case will usually end only when you’ve done a lot of correct things.
Hello doctor, quick question.. if the patient is unstable, do you put in the emergency orders first then assess the patient or do you assess first then put in the orders?
I usually first do a focused physical examination. This does not mean that my approach is necessarily correct because no one is sure how the CCS cases are scored. I personally preferred this and felt more comfortable about my performance with this approach.
This is important question of priority when it comes to emergency situation. It depend on the emergency case. If the patient is SOB and Hypoxemic then you should put them on O2 first then do your focused physical exam. If the patient has low blood pressure you should put IV access and start fluid then do your focused physical exam. If the patient has Seizure you should put IV access and give Ativan, O2 and check Glucometer then do focused physical exam.
Thanks for your nice explanation. One thing, ct needs to be done before getting the lumber puncture fluid level, rt? But In the case, I do it simultaneously. How can we order them separately?
I found it very confusing, sometimes if the patient is in pain but the treatment requires pain meds (ex. pancreatitis), if I ordered it on first pass css seems to deduct points for "treating before diagnosing"... UW seems to be a bit different than CCS, and the NBME ones seem to tell us not to order extraneous things even tho the CCS cases website usually don't care unless you order something contraindicated or too invasive. Who on earth to I trust? T.T
I recognize it can be frustrating. There are some things at times I felt ccs cases are too picky on. I would say to avoid fixating on those little things and make sure you were able to grasp the majority of the case. Things like right diagnosis, right treatment, right setting, etc… are more important. Again, no one truly knows how the true exam grades your score, so these small things may not even be incorporated into the final score.
It just depends on the case. In both of these cases, oral medications are not really going to act as quick as IV medications. In other cases where they’ll likely be sent home (e.g. patient with GERD without red flags), oral meds (e.g omeprazole) could be given. Generally, one route is not better than the other. You instead must tailor your answer based on the knowledge you learned from medical school and studying for the STEP exams. I hope this answered your question. Best of luck!
@@niveditasingh6333 if you mean “is it required to apply for residency?” Then the answer is no, you don’t need to complete it. Most people complete the step 3 during their first year of residency but some choose to take it before then for various reasons. I go over all of this in my STEP 3 video: ruclips.net/video/NWJxOgbmHG0/видео.html
Key points:
1. Timing (1:01)
Real time = the actual time/real world time, which is 10-20 min.
Simulated time = hypothetical time, which can last from hours to days to weeks.
2. What to look for in case's introduction (2:18)
Age
Gender
Allergies
Main HPI points
Screening (vaccinations, pap smear, colonoscopy, etc)
3. Physical exam (3:45)
Complete physical exam --> if patient is stable or in the office
Focused physical exam --> if patient is unstable or in the ED; you can always do a complete PE later in the case after putting in emergency orders!
4. Disposition (4:35)
Where do you want the patient to be? Options: home, ED, admit to inpatient, admit to ICU.
5. Emergency orders (5:55)
MAVOCCF, which stands for:
Morphine
Acc (gives you IV access and glucose accucheck)
Vitals check
Oxygen/oximeter
Cardiac monitor
C-spine
Fluids (normal saline)
6. Routine orders (6:51)
CCCMP
CUAEH
LLUSCENT
stands for:
CBC, CMP, Creatine phosphokinase, Magnesium, Phosphate
Chest x-ray/other x-rays, Ultrasounds, Abg, Ecg/other cardiac tests, Hcg
Lactate, Lft/pt/ptt/inr, Urinalysis/culture/toxicology, Stool culture/pH/ova/etc, Culture (blood), Esr/crp, Neuro checks, Tsh
7. You should land on a diagnosis by this point and thus, a treament (9:09)
8. Case might finish early if you have managed the patient correctly (9:27)
9. Once the case finishes, you have 2 minutes at the end to put in last minute- orders (10:00).
These can be pap smears, colonoscopies, vaccinations, counseling the patient on various topics.
SITPM (vaccines)
CPM (screening tests)
ISSSAD (counseling)
Shingles
Influenza
Tetanus
Pneumococcal
Meningococcal
Colonoscopy (50-75 yrs, every 10 years)
Pap smear (21-65 yrs, every 3 years)
Mammography (50-75 yrs, every 2 years)
Instruct
Smoking cessation
Safe sex
Seatbelt
Alcohol abstention
Disease specific (diabetes, medication side effects, etc)
Here is a summary of the entire first part of the video (some of this is abbreviated so hopefully it makes sense, but you can watch and read along)
CCS Cases
Things to look for initially (brief skim of H&P) - write these on scratch sheet
1. Age
2. Gender
3. Allergies
4. Brief skim of hx
5. Screening/vaccines/social hx (smoke, drink, drugs, sexual hx)
**skimming hx - buzzwords (they don’t want to trick you, dx is sometimes very very obvious)
ex: RUQ pain exacerbated by fatty foods - gallstones
They want to see if you can put in orders correctly, in correct order, and rule out other scary things (i.e ACS, pancreatitis etc)
VS
Exam:
1. If pt stable (i.e. in clinic and HDS) - complete physical (especially hitting the things they present with)
2. If pt unstable - not doing complete PE, wastes “simulated” time, need to “act fast” and do a focused PE
Disposition - Where do you want the patient to be?
1. Home
2. ED
3. Admit
4. ICU
STAT orders - Do you want to place any emergency orders?
Mnemonic - MAVOCC + F (not all needed, but reminder of some HY examples)
1. Morphine
2. ACC (gives you IV access and glucose accuchecks)
3. Vitals check
4. Oxygen/oximeter
5. Cardiac monitor
6. C-spine
7. Fluids (NS)
Orders (mnemonic) - tailor these tests to your ddx, don’t order all every time for every patient
CCCMP
CUAEH
LLUSCENT
1. CBC
2. CMP
3. Creatine phosphokinase (CPK/CK)
4. Magnesium
5. Phosphate
1. CXR (or any XR)
2. US
3. ABG
4. ECG (other cardiac tests - echo, troponins)
5. B-HCG (repro age like case will end early and you have 2 minutes at the end to put in extra orders
**refer back to scratch paper for quick reference for these below
1. Screening tests - i.e. colonoscopy, Pap smear, mammography
2. Vaccines - shingles, tetanus, pneumococcal
3. Counseling patient - i.e. smoking/drinking/drug cessation, medications, compliance, side effects, safe sex (if STI case), seat belt
SITPM
CPM
ISSSAD
SITPM
Vax - based on case, age, gender etc
1. Shingles - zoster max - >50 yo, 2 dose series, now then in 2-6 mo
2. Influenza/COVID - fall/winter season (RSV >60 yo)
3. Tetanus - q10years
4. Pneumococcal >65 (or susceptible to encapsulated organisms)
5. Meningococcal - 2-dose at 11-12 yo and 16 yo
CPM
Screening
1. Colonoscopy - 45-75 yo (q10years if no abn)
2. Pap smear - (21-29 yo) q3yr w/ cervical cyto alone
- (30-65) q3yr w/ cervical cyto alone, q5yr w/ high-risk HPV testing alone, or q5yr w/ hrHPV w/ cyto (co-testing)
- Chlamydia/gonorrhea - all sexually active women 25 yo at increased risk for infection
3. Mammography - 50-74 yo - biennial screening
ISSSAD
Instructing patient - when you type “instruct” into order search, gives you lots of options
1. Instruct
2. Smoking
3. Safe sex
4. Seatbelt
5. Alcohol abstention
6. Disease specific instructions
This was a phenomenal video bro. I used all your ccs mnemonics and tips and passed with ease. Thank You !
Glad it helped you!
By far the best video on this content. Thank you so much for taking the time to make this!
Very helpful. Makes CCS feel less overwhelming. Thank you!
my test is on Monday and this was great!!! you gave me some ideas on how to optimize my time. thanks doc!!
This was extremely helpful. Thanks so much for putting this together.
Where are u located?
That lemon tree looks stunning !
one of the most informative videos of my lifetime really really thank you
Super Helpful. Instead of trying to memorize those terrible acronyms, I changed a few.
Emergent orders : FAV-MOCCA
Workup orders: LUNCHMEATS 4CLUE-P
Admit/Treatment orders: CICADA FLAB
Closing orders: STIMP shots and CP SADISMS
The admit/treatment one I made up: Consult, Insulin, Counsel meds, Abx, Diet, Acid, Fever/pain, Laxative, Activity, Blood (T/S/Transfuse)
Elaborate on your mnemonics please
Emergent orders: FAV-MOCCA
- F: Fluids
- A: Airway management
- V: Vital signs monitoring
- M: Monitor (cardiac)
- O: Oxygen administration
- C: Cardiac monitoring
- C: Chest X-ray
- A: Arterial Blood Gas (ABG)
Workup orders: LUNCHMEATS 4CLUE-P
- L: Lactate
- U: Urinalysis/culture/toxicology
- N: Neurological status monitoring (Glasgow Coma Scale/pupil reactivity)
- C: Coagulation studies (PT/INR/PTT)
- H: hCG (pregnancy test in childbearing women)
- M: Magnesium
- E: ESR/CRP (inflammatory markers)
- A: ABG (Arterial Blood Gas)
- T: TSH (Thyroid Stimulating Hormone)
- S: Stool studies (culture/pH/ova and parasites)
- 4C:
- C: Complete Blood Count (CBC)
- C: Comprehensive Metabolic Panel (CMP)
- C: Creatine phosphokinase (CPK)
- C: Cultures (blood)
- L: Liver Function Tests (LFTs)
- U: Ultrasound
- E: ECG/Echocardiography/Cardiac enzymes
- P: Phosphate
Admit/Treatment orders: CICADA FLAB
- C: Consult
- I: Insulin
- C: Counsel on medications
- A: Antibiotics
- D: Diet
- A: Acid control (antacids/proton pump inhibitors)
- F: Fever/pain management
- L: Laxatives
- A: Activity level
- B: Blood (type and screen/transfuse)
Closing orders: STIMP shots and CP SADISMS
STIMP shots (Vaccinations):
- S: Shingles vaccine
- T: Tetanus vaccine
- I: Influenza vaccine
- M: Meningococcal vaccine
- P: Pneumococcal vaccine
CP SADISMS (Screening and Counseling):
- C: Colonoscopy
- P: Pap smear
- S: Smoking cessation counseling
- A: Alcohol avoidance counseling
- D: Disease-specific counseling
- I: Instruct patient (provide specific advice)
- S: Safe sex counseling
- M: Mammography
- S: Seatbelt use counseling
Thank you, found this video the day before my exam, and it helped a ton!
I really needed this video. Thank you so much
You are most welcome!
Wonderful! Really helpful. I can finally open my CCS and start solving the cases with confidence!
Wow, this was so incredibly helpful!!
Thank you .I would like to know why you do the physical examination twice?
I do a targeted exam initially to save time in case there is anything we need to urgently act on. The second is to complete the remainder of the exam to be thorough and not miss anything.
Thank you man that was helpful, God bless
This was amazing, thank you!
SO helpful! Thank you!
Hello, Love the video! Is the abnormal result highlighted/starred on the real exam also?
Glad you enjoyed the video! No, the real exam does not tell you what you did right or wrong. In fact, no one knows how the real exam grades your performance. I do think ccscases does a good job of giving feedback and simulating the test taking environment even though it may not necessarily be exactly like the real deal’s scoring style.
Thank you so much for the video. It's really helpful! I don't think you need prophylactic cefazolin on the cholecystitis case as you already started therapeutic piperacillin-tazobactam. Thanks again!
You are an absolute legend.
excellent teaching thanks so much
I have an issue with the re-evaluate case, can you please explain how to use the "on" "in" and the others to really maximize time, I hope you see this, thank you for the video also!
I think you’re referring to when you click on the clock and run the time forward. If this is what you mean, I usually click “next available result” because it saves me time from typing exactly how far ahead I want to go.
On refers to a certain time you want to go forward to; for example, if it’s 10:15 and you want to skip to 10:45. You would just write “10:45”.
In refers to how much you want to skip ahead, using the same example, to skip ahead 30 minutes, you would write “30”.
I don’t like to use these because you have to check exactly how far you want to skip ahead and to check you have to click around a lot which will cost you some time (especially with input delay).
@Khalemedic Thank you so much, just saw this! Do you have any websites where I could purchase materials for you just to gain more knowledge? Really appreciate you!
What about choosing "call /see me as needed" to move forward? Would that be a sound choice?
From my experience, it can sometimes lead to the case finishing without completing everything. If you avoid using that option, the case will usually end only when you’ve done a lot of correct things.
very helpful!! thank you!
Hello doctor, quick question.. if the patient is unstable, do you put in the emergency orders first then assess the patient or do you assess first then put in the orders?
I usually first do a focused physical examination. This does not mean that my approach is necessarily correct because no one is sure how the CCS cases are scored. I personally preferred this and felt more comfortable about my performance with this approach.
This is important question of priority when it comes to emergency situation.
It depend on the emergency case.
If the patient is SOB and Hypoxemic then you should put them on O2 first then do your focused physical exam.
If the patient has low blood pressure you should put IV access and start fluid then do your focused physical exam.
If the patient has Seizure you should put IV access and give Ativan, O2 and check Glucometer then do focused physical exam.
Thank you so much!!
Thanks for your nice explanation. One thing, ct needs to be done before getting the lumber puncture fluid level, rt? But In the case, I do it simultaneously. How can we order them separately?
You can order the CT, advance time, then order the LP once the CT is clean.
I got 70 percentage in the 12th class.... does it cause any issues while doing pg in medicine (usmle, plab).....plz reply me plz ....
@@kookie-rd6pe NO
Thanks!!!
You bet!
Why are LFTs included in the pneumonic if CMP is already in there?
Great point! CMP’s include LFTs. You can just think of Lactate when it comes to L.
Thanku so much 😊
Thank you
tytyty very helpful
Thank you!
THANK U
I found it very confusing, sometimes if the patient is in pain but the treatment requires pain meds (ex. pancreatitis), if I ordered it on first pass css seems to deduct points for "treating before diagnosing"... UW seems to be a bit different than CCS, and the NBME ones seem to tell us not to order extraneous things even tho the CCS cases website usually don't care unless you order something contraindicated or too invasive. Who on earth to I trust? T.T
I recognize it can be frustrating. There are some things at times I felt ccs cases are too picky on. I would say to avoid fixating on those little things and make sure you were able to grasp the majority of the case. Things like right diagnosis, right treatment, right setting, etc… are more important. Again, no one truly knows how the true exam grades your score, so these small things may not even be incorporated into the final score.
@@Khalemedic Ugh the ambiguity. Really appreciate the video and advice!!
Thank you so much
You’re most welcome!
awesome
I noticed you keep choosing Intravenous. Is that better than choosing orals in the exams
It just depends on the case. In both of these cases, oral medications are not really going to act as quick as IV medications.
In other cases where they’ll likely be sent home (e.g. patient with GERD without red flags), oral meds (e.g omeprazole) could be given. Generally, one route is not better than the other. You instead must tailor your answer based on the knowledge you learned from medical school and studying for the STEP exams.
I hope this answered your question. Best of luck!
Thank you so much
how the hell you keep these random mnemonics straight
Is it part of usmle exam??
Yes, there are 13 ccs cases at the end of day 2 of the USMLE STEP 3 exam.
@@Khalemedic I’ve heard , this time it’s only step 1,2 and OET. That’s y I asked.
@@niveditasingh6333 if you mean “is it required to apply for residency?” Then the answer is no, you don’t need to complete it. Most people complete the step 3 during their first year of residency but some choose to take it before then for various reasons. I go over all of this in my STEP 3 video: ruclips.net/video/NWJxOgbmHG0/видео.html
@@Khalemedic got it… Thankyou for responding 😊
Thank you !
Thank you😊😊
thank you!