There is a ccs case with TIA in UWorld, I did everything required and asked vascular consult for CEA but he is not accepting, is there something wrong with the algorithm. It is driving me crazy, Is UWorld reliable to practice. Guys , please let me know if UWorld has any shortcomings comparing to the original ccs software of exam.

Hi There,

Usually when you make a vascular surgery consult or any surgery consult for that matter, surgery criteria or orders have to be met and also the PROCEDURE that you want done. For example on the TIA case:

Doppler US shows >70% L.Artery stenosis

you would order: Vascular surgery consult, CEA (carotid endardectomy),

the same way you would order: surgery consult, laparotomy

obgyn consult (PID), surgery consult, laparoscopy

The surgery orders usually calls for:
diet, NPO
bedrest
Iva, IVF (NSS), foley, urine output, ant-emetics, antibiotic (usually cefazolin for pre op abx 1x), pain meds, blood type and cross, pt, ptt/inr,

also keep in mind, sometimes the consults have no advice and sometimes they do
"the pt will be scheduled for surgery, continue medical management."

hope this helps.

Thank you very much for your reply. I was just ordering the consult and the reason for the consult without ordering the procedure, because I think it is safer to write the procedure after the consultant accepts the pt for procedure which I mentioned in the reason for consultant. I got this idea from archer. please correct me if my thinking is wrong.
One more thing, I used to order blood group and cross match, pt ptt inr npo and urine output, iv access, fluids but not antiemetic and antibiotics prior to ordering consult. because we don't know whether the consultant will be taking the pt for procedure or just suggest medical management as you said. Thanks in advance.

similar thing happened with chest pain, I followed every thing as mentioned in the clock management and approach but when I ordered cardiology consult thinking that he will take for catheterisation as he has risk factors and other indications for the catheterisation. I did everythng exactly as mentioned waiting for him to accept the patient for procedural management. but he said no explicit management.

Dr. Rocky,

I can only tell you what helps me when i perform the cases. I have read the "scoring" tabs, and "timing" tabs, they will help you along.

You SHOULD place all your orders simultaneously and forward to consult recommendations. if they don't have any recommendations,still forward the clock to the the procedure and it should have been performed without difficulty. (this also helps with time management to assess the stability of your patient)

If the computer does NOT allow you to perform the procedure, it means that the surgery criteria was not met. Read the scoring tabs and understand why you should be entering those orders simultaneously. You do not have to wait to review the consult to order the procedure.

if you order a consult, without naming the procedure (you have wasted his time)

The consult wants you to know why you are consulting them (usually to perform the procedure), the consult wants you to have medically manage the patient and get them ready for surgery before he/she assesses the patient.

If the consult feels you have adequately managed the patient, it will usually allow "the pt will be sent for surgery, continue medical management.", forward the clock to procedure time.

so for the case with Chest Pain:

you will order all together
cardiac/vascular consult
cardiac cath (you want to see where the blockage is)
PCI (correct the blockage)
forward to PCI, the procedure should have been done once you made all the necessary orders.

usually if you "poke" procedure: 1 x pre-ob abx is warranted.
Specific empiric abx are used for cases such as meningitis (vanco, ceft, steroids), GI cases (Diverticultis, amp-sulbactam), cellulitis (clindamycin)etc, specific rx oncle blood cx and sensitivity returns.


Another thing that has helped me is: Pay attention to VS
if the pt has nauseau, and has vomited, what is stopping you from ordering Phenergan?
depending on the case, also address pain. If the patient won't allow you to examine them, because of extreme pain and you need further clinical history (such as PE findings) to rule in/rule out diagnosis you should give them 1x Morphine.

if you don't want the pain to be masked, such as in appendicitis for example (you should not order Morphine), order it once your PE is complete.

the CCS cases, test your approach, management and monitoring parameters which includes f/u, labs and interval history.


i hope this helps.

Dr.Napa,

Is it important what we write in consultation. Would that be ok if we keep it as short as possible?

Thank you.

Hi,

According to the step 3 content, that can be found on usmle.org

Diagnoses and reasons for consultations that you
provide in Primum CCS will not be used in
evaluating your performance at this time, unless
needed to investigate unusual test-taking behaviors
or response patterns


https://docs.google.com/viewer?url=http://www.usmle.org/pdfs/step-3/2014content_step3.pdf

if you are good with time, i would just type the reason, ie. "appendicitis on CT"

hope that helps

Yes. Thank you so much!

These tips were very useful. Thanks for taking time to reply and clarifying my doubts. One more concerning part in ccs, sometimes the explanation is lacking the frequency of administration of medications. when to use continuous and one time.

Hi Dr. Rocky,

i found the "clock management" tab to be useful.

they write the orders as "continuous" or 1x

hope that helps

Dr. Napa,

Can I also ask about the break time on Day 2? I am not clear if the 45 min break time is for MCQ and CCS part of the exam combined or for each section we have separate break time!
Do you know how much break time we have during CCS cases?

Do you suggest to take some notes (such as pt age, social history, last pap or mammogram, etc.) while we read the history?

Thank you for your time and suggestion.

Hi There!

I believe the total break time for the entire day is 1 hr. 45 total mins minimum break time, plus 15 mins (if you do not do the tutorial.) quickly go through the tutorial to make sure sound is working.
The second day of testing includes 144 multiple-choice items, divided into 4 blocks of 36 items. These blocks will take 45 minutes. (4 blocks at 45 mins= 180 mins which is 3 hrs) The total time allotted for these blocks is 3 hours.

The second day also includes a Primum® Tutorial and instructions for which approximately 15 minutes are allowed. This is followed by 12 case simulations, for which 4 hours are allotted. A minimum of 45 minutes is available for break time.

and absolutely, you should be note-taking now as you practice. I find age, vitals and sx to be particular useful for sx management in the cases (so for example, if my VS are stable, but the patient as vomited or has pain, i will order Phenergan, and Morphine (if it will not mask sx), and if VS are unstable and in the ER (i order Emergency Orders, which are kind of standard: oxygen, pulse ox, cardiac and bp monitor, ecg, iva, (abg in resp cases), AMS (blood glucose, AMS suggesting drug intoxication (would have to do PE to look at pupils, respirations etc: everyone gets glucose, thiamine, naloxone, utox) and always make sure you take your blood cx first before ordering your empiric rx.

routine screenings for age, colonoscopy, pap, mammogram and vaccines useful for 2 min end case screens if not pertinent to dx.

i read the step 3 content, which i copied and pasted before. It explains what is graded and what is not. reasons for consults are not graded, and counseling is not heavily weighted unless it pertinent to dx. of course you should briefly "counsel" in all cases to make sure you get points for counseling, but specific counseling to the case only if pertinent , such as "asthma care, cancer diagnosis, std counseling and safe sex (PID, STDs), medication compliance (HAART, COPD, etc)

i hope that helps.

Thank you SO much for the helpful suggestions and detailed explanations!

So on Day 2 we have 1 hour for total of 7 hour exam (3 hr for MCQs and 4 hr for CCS part) this also includes lunch break! right?

Thanks again!

4 hrs CCS, 3 hrs mcq, 1hr break time

Got it. Thank you!

I forgot to ask two last qs!!
When the patient has SOB in ER and we start with pulse oxy (takes 5 min to get the result)...should I wait for the results first before a focused Physical exam (waste 5 min) or can I do my 7 min PE (general, HEENT, lung, heart, abdomen, extremity (7 min) meanwhile and then give oxygen (with 2 min delay!!)

and when for a routine order I get a notice to choose between wait on a Queue for a routine order or choose stat, would that be ok it I choose the Queue and get the order with some delay or should I order it as stat instead?

Thank you so much again, I really appreciate your time and suggestions!

I just wrote a reply and it wouldn't let me post. First let me just say that I by no means am credential or licensed to know how the ccs is graded. I am simply providing insight for what has worked for me in my experience and in my review with the information provided by the usmle.org website and the uworld software.

to answer your question:
1. Do NOT wait for the results of the pulse ox. Think of this patient as a real patient. By the time you do the focused PE, the results will be back. If you wait, there's a good chance the patient could desat into respiratory fatigue and failure and you could kill this patient.

2. if your routine orders are at the 2 min end case screen, go ahead and order them stat, unless it is a monitoring parameter that is considered routine for f/u (INR on Warfarin, annual pap, mammogram, vaccines.) Stat for maintenance meds or orders needed for the dx and rx of the case should be stat. (this is just my opinion because sometimes the case ends once you've fulfilled the algorithm. so i want to be sure the computer recognizes that this is how i am managing my patient.

i hope this helps
edited by on 8/10/2014

Thank you so MUCH for your suggestions and thanks for sharing your experience!

Hi Guys
Any one know if points get deducted when you order everything "stat" so you don't have to wait for the computer to decide when it will give you the results of the particular studies or labs that you are ordering ? For example, I know I can forward the clock however this does not ensure that the results will be ready. Its much easier to order labs and studies STAT and the results will be available right away.

If anyone has an opinion or by any chance that they know for sure please let me know.

Dr. Palma