2020. 3. 4. 00:21ㆍ카테고리 없음
Based on customer feedback and expert opinions, some cases are felt to be extremely high-yield and a large number of these important cases are discussed inIf you’re getting ready to take the USMLE Step 3, you must study and practice CCS prior to the exam. ArcherReview.com provides live interactive reviews of CCS. Each workshop is taught in a webinar event, allowing students to review CCS from the comfort of their own homes and to watch and practice CCS cases under supervision in a virtual classroom. Students save both time and money on their CCS review.Each live is designed to strengthen students’ approach to patient care. Students learns how to maximize the delivery of quality care in the 25 minute time allotted for each CCS simulation and how to follow through on critical CCS tasks.The CCS workshop is set up as a combined lecture and hands-on learning environment. Every student gets to practice CCS and have his or her CCS methods analyzed by professionals.
On said:Solving Case 94ALL in a 5 yr old boythis was a 5 yr. Old boy who came with weakness, disinterest in activity and lesion on leg.
On examination, the lesion was ecchymosis and there was generalized lymphadenopathy with liver enlargement. ( CBC, BMP, LFTs, LDH — revealed CBC: anemia, thrombocytopenia, neutropenia, lymphocytosis with 95% lymphocytes on DC, peripheral smear shows blasts ( schistocytes if there is concomitant DIC), LDH elevated in leukemias/ lymphomas, hepatosplenomegaly on ultrasound, CXR: many enlarged lymph nodes, then now need to do bone marrow biopsy ( diagnostic step) and this reveals many lymphoblasts, Admit and call ped/onc, ct chest and abdomen ( shows wide spread lymphadenopathy), bone scan, karyotype- counsel: cancer diagnosis. Check PT/PTT, FDPs and Fibrinogen to r/o DIC as 10% ALL patients may have DIC. If there is fever at presentation, make sure to get pan cultures.
Make sure to order “neutropenia precautions” if there is absolute neutropenia ( ANC. On said:Solving Case 9220 month old boy/ Iron Deficiency Anemia20 month old african american boy brought for fatigue and lethargy to office (initial orders – CBC reveals anemia, MICROCYTIC TYPE – do iron studies ( serum iron, ferritin and TIBC), blood lead levels, reticulocyte count, LFTs, haptoglobin, sickle screen and LDH – ferritin low. No evidence of hemolysis ( r/o sickle cell at this time), do stool guaic ( rectal exam in the beginning itself r/o blood loss as a cause of fe def ) – Fe defeciency diagnosed which is most common in children during growth spurts if nutrition is not adequate ( remember you already ruled out other causes of Fe deficiency i.e; lead poisoning, GI blood loss, ongoing hemolysis). Order iron rich diet ( very important to order this diet since lack of balanced diet is the reason for Fe def in children during growth spurts), iron oral pills ( FERROUS SULFATE)- check cbc in 1 month/ schedule follow up visit – usually blood counts return to normal in 2 months – so, schedule follow up CBC and Ferritin level for “LATER” date i.e; 2 months later on 5 minute screen ( continue ferrous sulfate for at least 6 months even when blood count normalized). On said:Solving Case 91.Dehydration/ Hypernatremia in an Elderly man70 y/o man with altered mental status, no urine output sent from NH to ER. ( BMP comes back shows NA + 160, BUN high, Crea normal) – two things here, this patient has confusion which could be secondary to dehydration or hypernatremia. Marie, on said:Dear sir,How are you?
I enjoyed your CCS session last sunday. I have one queston for you.I was doing CCS cases in USMLEWORLD software.In one case pt came with HTN of 230/140,severe headache,nausea,vominting.
I gave himNitroprusside IV one bolusmetoprolol IV continuousphenergan iv one timeMorphine Iv one time.In the expanation USMLE world gave for this case,they managed with Nitroprusside alone.(Arerial Line).no other medications. On said:You did well.Here the symptoms – headache, vomiting are due to raised intracranial tension from Hypertensive encephalopathy.
So, they should improve on rxng the blood pressure alone. However, you can use symptomatic therapy like tylenol and reglan or zoffran. Phenergan may cause sedation – so stay away in this case.Sodium nitroprusside is not given via. Arterial line. You probably interpreted it wrong. Arterial line in this case is used to monitor the blood pressure closely and accurately so as to get an accurate reading on Mean arterial pressure (MAP). As you monitor the BP via, arterial line, we can adjust the rate of IV nitroprusside so as to achieve the goal MAP ( make sure not to drop it too fast either).
Monitor with A line and order continuous BP monitor along with check, blood pressure every 1hr. Order neurochecks every 2 hrs. HEENT exam on physical to check the eyes and possible papilledemaHypertensive encephalopathy begins slowly with onset of headache, nausea and vomiting and then, non focal neuro deficits. In the case above ( note that they gave blood pressure 220/120, which is a cut off BP to start antihypertensive therapy even in a ischemic stroke), if the history or focused physical is not suggestive of ischemic stroke (i.e; no focal neurological deficits), one should not wait until the CT head is completed to start an antihypertensive agent. CT must be done to rule out cerebral hemorrhage but one should not wait until CT comes back. If you are trying to rule out ischemic stroke based on the CT alone realize that it might not even appear on the CT for first 24 hours. As such, MRI is the best choice to differentiate hypertensive encephalopathy from ischemic stroke but MRI is even more time consuming.So go by your clinical exam and history.
Because neurologic symptoms ( non localizing neuro deficits like restlessness, confusion, seizures and coma) in hypertensive encephalopathy differ from the sudden onset of focal neurologic symptoms typically seen with a stroke or hemorrhage. Do order a CT scan of head, BMP, Cardiac enzymes ( to rule out other target organ effects like renal failure and myocardial infarction), CXR, EKG, 2D ECHO, and also start antihypertensive agent on the first screen itself when bp is greater than 220/120.
It seems like in the scenario you mentioned, they have waited at least 30 minutes ( CT scan takes 30 mins in ER on the CCS software) which is a delay in managing the above patient.If BP is less than 220/120, obtain CT and wait for the CT results to r/o ischemic stroke/ hemorrhage and match with compatible physical exam findings to conclude that it is hypertensive encephalopathy. If no evidence of ischemic stroke, start nitroprussideNitroprusside is usually the drug of choice especially when SBP 220. Other drugs that can be used are labetalol, nicardipine and fenoldapamNow, as you run the drip and monitor BP, the case might end.
Sometimes, the case may take you to the next day and farther. Once, patient is clinically better, start oral medications and taper off nitroprusside ( on CCS, monitor BP after starting oral meds and then stop the nitro drip).If case ended and you are on 5-minute screen – think what could have caused her HYpertensive emergency? Follow up care, later tests and further work up are important on 5 min screen.Most important cause of hypertensive urgency/ emergency is non compliance with medications. However, Work up for secondary hypertension is important in the patients presenting with emergencies like this – i.e; especially if these patients were compliant or if there are any clues to suggest a secondary cause in the history ( episodic headache, palpitations, episodic and labile bp) or physical ( abdominal bruit) or on the labs ( hypokalemia). Order MRA of the renal artery, Calcium level, TSH, plasma metanephrines and obtain PAC/ PRA ratio.
Discontinue NSAIDS if the patient is using them for some reason. Paula, on said:Dear Dr.
On said:Hey Paula,All stable nephrotic syndrome (NS) cases are managed as outpatient.An outpatient NS child can be treated with salt restriction and prednisone trial. Prednisone should be at least 4 weeks. If things dont improve, prednsone should be continued for another 4 weeks before going for renal biopsy.Pneumococcal vaccine should be given to all NS children because they are at high risk of bacterial infection ( include it on your 5 min screen orders)NS is a hypercoagulable condition secondary to loss of anti-thrombin III. But there is NO role for DVT prophylaxis with heparin or warfarin in NS. So, the only thing you need to do is ordering activity such as “ambulate” on CCS ( early mobilization)INPATIENT:Nephrotic syndrome patients should be admitted if they have:a) Intravascular volume depletion ( presenting as orthostatic Hypotension or Shock)b) Massive Pleural effusions/ Ascites ( presenting with SOB and rales on lung exam).Once you admit, realize the reason why you are admitting.If the reason is orthostasis/ hypotension – give albumin infusion as albumin mobilizes fluid from outside in to intravascular compartment. This may treat orthostasis. DO NOT USE DIURETICS YET UNLESS THE PATIENT IS COMPLETELY VOLUME STABILIZED.
( Unlike the way they did in UW where they claim that patient is orthostatic and dehydrated and they are also starting lasix even before orthostasis resolved – This is a wrong approach because they should first satbilize the volume. Giving aggressive diuresis in that patient who came with dehydration would cause further volume depletion and may precipitate acute renal failure. Dhara, on said:Hello Doctor,1. I did CCS case of HYPERTENSIVE EMERGENCY on USMLEWORLD. When i order ctscan, report time was after 4hrs.
It was obvious from physical that he had organ damage like eye changes, raise bun/creat, bp was 230/180. No focal deficits pointing to stroke so i did not wait for 4 hrs and went ahead and gave him IV notropruside., but aassesment says we should start antihypertensive after comfirming no stroke from ctscan.should i follow that protocol or am i right in giong ahead and giving him antihypertensive?does ctscan take really this much long time in real life i don’tthink, but we should not let pt die in those 4 hrs waiting scan, i mean anything can happen with that high bp.?2.
Please tell me how to differentiate bell’s palsy, stroke, lyme facial palsy? First and foremost, CT scan takes only 30minutes to come back in the ER setting. If there are no focal neuro deficits, you can start nitroprusside with out waiting for CT however, in a comatose patient it is some times difficult to assess the neurological function. So, wait for Ct and then start nitroprusside. Waiting for 30 minutes for CT is not a big thing.I guess if you are using USMLEWORLD software, as per some students, several test report time is wrong there as they did not adequately adjust the report times based on location and some one should write to them to correct those.You can try putting CT head, stat on the original test software.
The report time changes based on the location. The report time for a CT head stat is 30 minutes in the ER. The report time for CT Head stat is 4 hours in the office. Try it on case 1 and try it on case 2 on the test software and you can appreciate the difference.Even if your patient came to the office, if you think you need a stat CT you should send the patient to ER and then order a stat CTQ2) clinically, bells palsy involves the whole side of the face where as UMN facial nerve stroke involves lower part of the face unless it is a cortical (central) facial issue. If clinically you have a problem differentiating, CT head and MRI can help r/o stroke.Clinically it is difficult to differentiate Late lymes from bells palsy. You need to suspect lyme based on endemicity as well as risk factors like previous tick exposure.
If you suspect it, Get a lyme serology. IF serology -ve, rx as bells ( acyclovir+steroids). If serology +ve, use doxycycline.
Gazinto, on said:. I just wanted to thank you! I have not yet received my score, but I felt very confident with CCS portion. I only had time to practice a few cases a read over some explanations in UW the day before my CCS part of step 3. I do not recommend this, but I had practiced CCS in the past. But the KEY FACTOR was your CCS lecture.
The day before day 1 of my step 3 i listened to half of your CCS lecture (which also helped me answering some MCQ’s) and then the other half when I got home after day 1. I cannot tell you how HELPFUL this was for me! I felt as if I was hearing you telling me what to do during the exam.
Thank youregardless of what my score isthank you! Huma Baqui, on said:Hi Dr REDI had taken the ccs workshop 2 weeks backI had a few doubts.1. On said:Dear Huma,Q1. If you can recall, I remember telling you some fatal mistakes in UW software during the workshop.This is one such fatal mistake in their algorithm writing and also not following the correct indication sfor Surgery. This should not lead you to think that surgery must be delayed. In the exam, if you find critical signs such as generalized rebound tenderness or rigidity, call surgical consult STAT andsurgery will accept that patient.
Once surgeon accepts, order pre-op orders. If there is no rebound tenderness or rigidity, one may wait as some small perforations may seal up — I mean to say if symptoms and signs of generalized peritonitis are absent, a conservative approach hence can be used but not when peritonitis is present.Q2. Again, I mentioned this in the workshop. Please do not go with what UW said in those cases, these are errors. UW is a good source but you should know these serious errors in some cases. In your exam, if you call the surgeon and if you have met the criteria for sirgery – Surgeon will accept.
Once you get the acceptance, put the pre-op orders such as NPO, IVA, NSS, Type and crossmatch, obtain consent and Name of the procedure.Q3. Once you place the patient on NPO, you may switch necessary medications to IV routeGood LuckRed.
On said:Anjum asked, ” In Usmle world I treid to do it but it did not allow me. Should I try on ecfmg five cases?”Yes Anjum.That is a big drawback with USMLE World software. It is not an exact copy of USMLE CCS Software. Please practice those usmle world cases on USMLE CCS Software. If you train yourself on USMLE World in the above way, you can get in to problems on the exam with the office cases. If you put in orders on USMLE Original software, you can see that it allows you to order follow up labs even when your patient is at home. This is what we all do in clinical practice as well.
A patient need not come to office time and again just for follow up lab work. Gennadily, on said:Dr. Red, thank you very much for good practice I got listening to your workshops. I think, it will greatly improve my score on Step 3. I have some questions and would like to ask your favor to answer. One of them is: what is your general approach in HIV case: something like office case of young pt with cough or diarrhea and no obvious h/o multiple sex partners.
In my opinion, it would be a good one to practice. Also, peds case of piloric stenosis or intussiseption. The other question is that my hours of watching running out quicker than I expected. Is it something wrong in the way they calculated? Because I resently purchased it, and it’s already just a few left. I think, every time I watch part of the video, it still counts as a whole video. So, if would clarify, please.
Next question, during workshops, you mention sometimes, question logs. Could you, please, explain what it is. Last 2 questions: what is the best e-mail to reach you, and how individual ccs tutoring works, price, hours, etc. Thank you!With respect, Gennadiy.
On said:Dear Adi,Thank you for your feedback.For all cases on hypotension, shock or dehydration i.e; the cases in which you already know that the patient is hypovolemic, it is important to use isotonic fluid such as 0.9% NS. Most other cases, where you start a temporary fluid before when you place a patient NPO, start 0.9% NS if you expect to start a diet with in next 24 hours.For cases of DKA, start with 0.9% NS but once sugar falls below 250mg%, change to d51/2ns. For cases of hyponatremia and hypernatremia, you must balance the fluid choice.
For example, for a patient with hypovolemic hypernatremia with out CNS manifestations, I would still use 0.9% NS where as for a patient with CNS manifestations and euvolemic hypernatremia, I would use 5% DEXTROSE IV ( This is like giving IV free water with No Na in it). For a patient with euvolemic hypernatremia with no symptoms, I would use free water orally. So, you need to apply the concept of IV fluid depending on the case you are dealing with. But for most other cases, just choose 0.9% NS.I have explained all the fluid choices and electrolyte management in Nephrology/ Acid-Base lecture.
If you need more information, please review it.Wish you all the best.Red. Adi, on said:Thanks a bunch Dr Red, as usual!I had another query pertaining to the differences between the management of NSTEMI and STEMI. Actually, there was some disturbance in the audio transmission at my end during that case due to which I did not get to hear to it in totality.i) I know thrombolytics have no role in NSTEMI.ii) What about heparin usage? I know that heparin is used routinely in NSTEMI. But we used heparin in STEMI too during the case practice that day?iii) GIIb/IIIa are routinely indicated in NSTEMI while they are indicated only before/during angioplasty in STEMI.
Right?iv) Angioplasty is not the front runner in management of NSTEMI unlike STEMI. But what are the indications to its use in NSTEMI? One that I could hear was when chest pain fails to show remission. Others?v) Any other differences?Thanks,Adi. On said:Dear Poonam,Only absolute contraindications to LMWH or heparin in the setting of acute MI is “active” “gross” or life threatening bleeding or history of Heparin induced thrombocytopenia.Bleeding in the past or occult blood in stool are not a contraindication to heparin in Acute MI setting because benefits far outweigh the risks of using LMWH in such acute setting.Not giving LMWH of Heparin based on these minor issues will reduce your score in the Acute MI case management.Best wishesRed. L, on said:Dear Dr.
Red,At the workshop, I remember you mentioned something about redo physical exam once the clock is stopped. Would you please tell me more about it? When I practiced office cases in the UW software, my patient showed up before the appointment time. I am not sure what happened there.
I didn’t know what to do. Is it a good strategy not to stop the clock? If unstable sign is present, can we just fix the problem right then rather than stopping the stock. I am not fully understood the consequence of stopping the clock and what to do afterward.Thank you. On said:Dear Nada, you are welcome. Thank you for your feedback.
If you are in Non-Internal medicine specialty; MCQs are usually, more difficult to improve when compared to the CCS. The best way to improve on the MCQs is to do a large number of questions so that your brain gets used to the complex analytical process. If your averages are too low, you must go back to the basics of Step 2CK to strengthen your clinical concepts and then, move on to Step 3 MCQs. I recommend that you take NBME Self Assessment a month prior to your exam in order to assess your readiness. Please let me know what your NBME scores are and I can guide you from there.Wish you all the bestDr.Red.
Nada Alhashimi, on said:Thank you Dr. Red for your concern,I did 1st NBMEset & scored 280 ( too bad). Last year, in my step 2 CK I 1st scored in NBME 240 then after 2 months 420, so I believed I will do OK in the actual test, but unfortunately I scored 193/ 78, while my step 1 was 202/83.I am an OBGYN, but concentrating most on medicine in my study and began since september 2011. I was hoping that will take my step 3 early Feb 2012, but I rescheduled when i found out my poor score.I did UW and average score was 60.I need a good score in step 3 so that I can at least improve the impression about step 2.thanks again and looking forward to hearing from you soon. Rp, on said:Dear Dr.
Red,I have another query. If you get time, Please reply on queries.In management of foreign body: should I wait for xray chest and xray neck results for ordering pulmonology consult and bronchoscopy. In UW format, even after getting results of both xray, when I order pedia pulmonology consult, they decline and say to manage medically. When I place order for bronchoscopy after getting pulmonology consult, software again ask for pulmonary consult. So in short, I have to place both consult and bronchoscopy order on same time.
You told to wait till consult done and then order procedure. Did bronchoscopy need consult? In foreign body case bronchoscopy is must. So if pulmonology consult say to treat medically. Should I order bronchoscopy though?Well, in USMLE practice session there is no case for foreignbody. So they usually decline bronchoscopy procedure.Please reply.Thanks a lot.
Mk, on said:Dr. Red:Thank you for the STEMI cases you presented in your 2/2012 and 3/2012 workshops.I am trying to understand the timing of the ER-ICU location change in UWorld Case 17 (Unstable Angina). The patient has ST depressions on EKG, and UWorld recommends cardiac catheterization per the 2007 UA/NSTEMI Guidelines Table 5.In both STEMI cases you presented on 2/2012 and 3/2012, you recommended ordering cardiology consult & cath directly from the ER. However, in UWorld’s recommended “Clock Management,” they transfer the patient to the ICU after his first set of negative cardiac enzymes, and only then do they consult cardiology, wait for their recommendation, and order cardiac cath & coronary angioplasty. Is there a reason one would first transfer a patient to the ICU in an unstable angina case w/ST depressions that requires cardiac cath instead of ordering the cath directly from the ER?Thank you. On said:Dear Mk,STEMI protocol requires you to act swiftly as soon as you make the diagnosis right from the ER. The goal is to keep the “Door to balloon” time under 90 minutes and you will be scored based on this fact.
Moving to the ICU from the ER is a waste of time – cath lab should be alerted and cardiology must be consulted directly from the emergency room as soon as STEMI diagnosis is made. In fact, transferring to ICU and wasting precious time in STEMI case can reduce your score on the CCS.Thank you. Suzi, on said:Hi Dr.
Step 3 Aa
Red,I have purchased your $88 CCS workshop and I found it awesome!
Download Archer CCS videos for USMLE Step 3 FreeIf you are looking for USMLE Step 3 exam preparation then no doubt archer CCS Videos are one of best resource to do your exam preparation. One of the most popular videos series watched through out world.There are other videos series as well but Archer videos series is no doubt the best one.
Archer Notes For Step 3 S 2
You can subscribe to these lectures at their website of archerreview.com with different packages for subscription.Download Archer CCS videos for USMLE Step 3 FreeIn this part of the article, you will be able to access the.pdf file of Archer CCS videos for USMLE Step 3 by using our direct links. We have uploaded Archer CCS videos for USMLE Step 3 Free to our online repository to ensure ease-of-access and safety.File. You might also be interested in: Sketchy Medical Videos 2017 Pathology Complete OnlinePlease use the download link mentioned below to access Archer CCS videos for USMLE Step 3.Download FileYou can download USMLE Books (Step 1, Step 2 & Step 3) with all links working from the link given bellow:Disclaimer:This site complies with DMCA Digital Copyright Laws.Please bear in mind that we do not own copyrights to this book/software. We’re sharing this with our audience ONLY for educational purpose and we highly encourage our visitors to purchase original licensed software/Books. If someone with copyrights wants us to remove this software/Book, please contact us. Immediately.You may send an email to admin@cmecde.com or adcmecde@gmail.com for all DMCA / Removal Requests.