CONQUERING THE STEP 3 USMLE

In a Nut shell:
Time for preparation: 4 months
Materials used:
MCQs: UWORLD Step 3, First aid Step 1 for Bugs and drugs- MOA (mech of action), Biostats
review from UW.
CCS: Uworld (51 +41 = 92 cases) and cases on official usmle.org (6 cases) = 98 CASES plus
Crush Step 3 CCS for the not so familiar cases.
SCORES:
UWorld SIM 1 score: 221
U world Sim 2 score: 225
Actual score: 242
STRATEGY:
MCQs: The Known devil
Do a complete review of the 1500 ish UW questions. It generally covers most of everything that
is going to be asked on the exam. Some suggested to read the MTB 3, which can help you with
the base, I suppose. Some management given in it were in contrast to UW, so I decided to stick
with one source ie UW. I covered all the Qs once and then repeated the incorrect ones only.
Though you may think that there are only 1500 qs, each question has its own weight. The
explanations for every choice should be read. And the questions were also difficult to answer for
example: there were clues in the Q stem which could fit any of the given answer choices, so we
need to know our subject in depth to arrive at the right answer. For me CVS and Endocrine were
the hardest, so I dedicated more time to master those. On an average I was scoring from 65- 70
% on my blocks. But Of course, I did them in tutor mode, so I really can’t judge my performance
there.
I am a great fan of the “Recall method “of studying, so I made questions for myself as I was
studying the blocks, I did not take notes. Instead I made flashcards of the concepts that were
difficult to remember. And when I reviewed the questions, I could just flip on the flash cards for
the answers. But, it’s up to you if you want to take notes, as some feel more comfortable reading
notes in their own writing.
Due importance should be given to Biostatistics and Ethics- again my weaker points. So I
decided to buy the UW biostat review, which helped me to review the concepts and it also had
some questions which helped for additional practice. Also, the Step 3 UW itself has around 120
biostat questions, which again cover many of the questions in the exam. So, make sure you give
due time to those plus study the formulas, revise them and work out a few problems.
CCS: The Unknown devil
Just as the title goes, much of the fear pertaining to the CCS was there because I did not get
much information about it. How do I prepare for it? What sources do I use? I went on many
forums to read on what the others were saying. But in the end, I figured that there was only “Do
the UW cases, you’ll be good”. Yet even when I finished the UW cases, (of which many were
pretty straight forward) - I did not feel confident about it, because I did not know whether I was
taking the right steps in the right sequence or not. Because even if you know the management
pretty well, sequencing your steps is important. Like placing emergency orders before examining
a pt who is in acute distress.
So, I came up with some practical approaches to the CCS cases, these strategies can help you in
your preparation for the CCS and soon you can build on it as you do more cases.
Let me outline a few differences between the UWORLD and the Official ie exam CCS software
You can select MULTIPLE OPTIONS in the order sheet in the official CCS software
unlike in UW CCS. In UW CSS, to select multiple options press on “ctrl” button on the
keyboard as you select the options with the mouse. That’s how I practiced on UW.
Some Orders in the UW CSS may give you more options in the order sheet than when
you place the same orders in the official CCS software. So, try to open both the UWCCS
and the NBME delivery software in your computer, and make sure that the same options
are reflecting in both.
For ex: When I type the order “IV” in UW CCS- it brings up [ IV access and various IV
fluids] so I can select them both with one command ie IV. But in the official CCS “IV”
only brings up “IV ACCESS” so if I want to order fluids, I have to order it separately.
The options of “Routine “or Stat” that come after selecting an order, have been removed
from the Exam software. (A BIG TIME SAVER) It is still present in UW CCS though.
At the 2 min screen- I was able to enter many counselling points on UW CCS than I had
time at the real exam. Because in the exam CCS, there is some lag once you place the
order so it’s important to prioritize which counselling points are more imp than others
and then click them first.
The diagnosis box at the end of the case have been removed from the exam software. Still
present in UW CCS.

In addition to the steps, I have also given the commands I used where I could come with multiple
orders on the screen.
For example, in an emergency case you need to order an IV Access and you want to
check the fingerstick glucose. Two separate commands would be “IV” and then “GLU”.
But I figured that if you type “ACC” it brings up both “ACCESS IV “and
“ACCUCHECK GLUCOSE” thus I can select two tests with 1 command.
So, lets start: The following are points that are a conglomerate of the information I
gained from reading various forums and coming up with a plan that suited me best. This
is merely a guide and not a hard and a fast rule, since no one is sure of how the CCS is
graded. So, read through these to get an idea of the approach to the cases:

STEP 1: Read the case history as its presented to you. Be as fast as you can, since in 10
min cases you have to save time by going through the case fast.

STEP 2: As you read, make some mental notes on whether the patient has
? Allergies to drugs- esp. penicillin, sulfa drugs.
? on any medications- these will be on the ‘order sheet’ screen, so you don’t have to write
it down.
? smoker/ drugs/ alcohol – so that you can counsel at the 2-minute screen
(I read that some actually write these down on the erasable sheet in exam, but I never had
the time for it. But you can, if you feel that you might forget. These points are pertinent
coz, suppose you have to give amoxicillin to a patient, but u missed/forget about the
penicillin allergy, that could really hurt the score, so yeah just saying)

Step 3- After the history, you must have realized whether the patient is in acute distress
or not. So here come 3 possibilities:
1. Routine patient in office- Do Physical Examination after case history ends.
2. Acute distress patient in ER- Do emergency orders after case history ends.
3. Acute distress patient in Office- This presents a dilemma: Do I put in emergency
orders or do I do the Gen app/cvs/rs exam or do I shift the patient to the ER as next
step?
I couldn’t get a clear answer anywhere- so this is what I did:
In patients with Acute distress- I gave Morphine and Vitals check- then did Gen app+
CVS+RS exam – then shifted to ER.
Once in the ER, I ordered the rest of MAVOC (given below) with Fluids and then did the
examination and went on to place orders.
Note: one important thing to note is that: You have to examine the patient ie at least do a
CVS/RS exam before shifting to the ER. Do not directly shift to ER after the history
ends, even if the patient is presented to be in acute distress in history-U need to see the
patient ie Examine CVS/RS before shifting to ER.

Step 4: EMERGENCY ORDERS:

M- (TYPE “MOR”) Morphine IV (can be given in all pain patients EXCEPT those in
HYPOTENSION as morphine leads to peripheral vasodilatation- give Fentanyl/
Ketorolac in that case).

A- (TYPE “ACC”) Select- “Access IV” and “Accucheck Glucose”

ROUTINE patients: FULL examination (yes COMPLETE examination incl PR/PV- so

ACUTE DISTRESS patients: Do RELEVANT examination only = GEN APPEARANCE

Step 6: As you start the examination, the orders that you placed as emergency orders will
give you updates.
Click “Continue” if the vitals are good.
Click “Stop “if you want to go and place orders before proceeding with the examination.

For example, after I have clicked the boxes in the physical examination and as it is
opening, I get an update saying that SpO2= 90%. If I have already ordered Nasal O2 in
my MAVOC orders, I will press “Continue”
If I had ordered only “oximeter” in my MAVOC orders, now I have to stop the
examination- go to Order sheet and put in Nasal O2. And then come back and check the
boxes for the physical examination again. (Though you might think that this could cost
you a few extra precious seconds, proceeding with the physical examination without
giving Nasal O2 can negatively impact your scores).

Step 7: Orders
Now the examination is completed- Go to the Order sheet and start placing your orders.
 As its often said, when you are under pressure it is possible to forget something, when
under normal circumstances you would have remembered. Say, we all know to order Ecg
in chest pain. Yet in CCS there is a possibility that you will order CXR and Cardiac
enzymes and forgot about the ECG.

So I came up with this mneumonic, that helped my mind to run over all the important
tests that I am supposed to order. I don’t order these tests for all the patients, if chest pain
then tests in relation to that and so on.

CCC
UAE H
LUSCENT

 C- CBC
 C- CMP ( BMP + LFT)
 C- CXR and CT scans ( If Lung case- think Sputum)

 U- USG ABD/PELVIS/KUB
 ABG (For all pts with resp distress)
 E- ECG (think of other test like- Cardiac enzymes, d-dimer, CT PA, Echo)
 H- HCG (urine preg test) (all females 15- 50 yrs.) it’s a crude rule, but just to rem it.

 L- LFT, PT/INR, PTT, Bleeding time

 U- Urine routine, Culture.

 S- stool- FOBT, culture, ova/parasite, leukocytes, Fat stain

 Culture- Blood (all fever cases)

 E- ESR

 N- Neuro checks (all altered sensorium pts)

 T- TSH
I know that the above is not exhaustive, it doesn’t cover the tests for acute pancreatitis or say
anemia or tests for auto immune diseases. But we will not forget those specific tests for specific
diseases, right?
It’s the urine preg test in reproductive age women, or the blood culture in fever cases that we are
most likely to forget. So, it’s those kinds of tests that I have incl in the above. You can add to
this, or create your own as you see fit.
 STEP 8: Now the orders have been placed, the next step is
In Acute distress pts: remember we have not completed the full physical exam- so now is the
time to finish that. Its important that you remember to complete the physical exam in all pts.
Once you complete the physical exam, the clock moves and the results of the updates will be
presented to you.
In Routine pts: You can move the clock to get to the test result that is most relevant to the case or
send the pt home with a f/up appt (usually in 1 week) and then review the test results.
Each time you send a patient home with a new medication- you have to “counsel”
regarding the medication side effects, adherence and “No alcohol” orders- . Don’t wait
until the 2-minute screen to counsel regarding the side effects and no alcohol, becoz the
pt is taking the drug now, the 2 min screen can pop up after 2 weeks of simulated time.
So if you are starting a new medication now, don’t forget to enter these counselling
points before sending the patient home.

 All the treatment and management points have been discussed well in UWCCS, and you
will become more proficient by doing the cases.

A Few thoughts:
In many forums there are students who say that we should not intubate any patient in the
CCS. But this is wrong, I had cases on my exam where I had to intubate-ventilate and the
patient’s vitals immediately improved. UW CCS doesn’t have any case where Intubation
is needed- but in the actual exam you may need to intubate a deteriorating patient. The
orders to give here are “INTUBATE” AND “VENTILATE” don’t just stop with the
intubate order.
You don’t have to provide any Ventilator settings. The case usually ends with an update
saying that the patient has improved (if Intubation was the appropriate treatment.)
Once you have given the appropriate treatment or the patient becomes better, you will get
an update that the pt is improving and then- the 2minute screen will pop up.
At the 2 mins page- type “counsel” and select all the counselling points that are pertinent
to that patient. But mostly you will have time for 4 or 5 only. So, pick the important ones
first say for ex: for a STD pt- partner counselling, contraceptive counselling here is more
imp than counselling on diet/exercise.
Much has been said about the CCS format- how it can make or break your score, and I
feel that it is right. It can certainly give a boost to your score.
Some other thing that was discussed in a few forums was like how it really doesn’t reflect
the real-world scenario and stuff like that. Though it may be true, we don’t have the
option of not studying for it. So yeah, there is only one way to face it: We have to prepare
for it and conquer it! It can be done.
ALL THE BEST FRIENDS!