The Ultimate USMLE Step 3 CCS Review solutions/
The Efficient USMLE Step 3 CCS Review
/Comprehensive USMLE STEP 3.
Case 1: 25F w/ dysuria, urgency, and burning, + suprapubic ttp. Afebrile, hemodynamically stable. No
vaginal discharge, no flank pain. Sexually active with husband, does not use contraception. LMP 24 days
ago. Smoker.
1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx ✅- Emergency orders (before PE): none
PE: general, chest/lung, CV, abdominal, genital exam
Order: UA, qualitative beta-hCG, ucx (with repeat in 1-2 weeks after initial to confirm eradication)
- then advance clock to see lab results
Orders: pregnancy counseling, prenatal vitamins (oral, continuous), 7-day course of nitrofurantoin (oral,
continuous) (or augmentin if allergic)
Now - change location to "home", schedule appt in 2 weeks, confirm move
Final orders: urine cx at 2 week clinic visit
Primary dx: uncomplicated acute cystitis and pregnancy
What is the treatment for uncomplicated cystitis?. What if they're allergic to that abx?
What is the treatment for complicated cystitis?
What is the tx for cystitis in pregnancy, and what if they're allergic to that abx? ✅- - Uncomplicated
cystitis --> 3 days of TMP-SMX: 3 days of fluoroquinolone if allergic.
,- Complicated --> 7 days of TMP-SMX
- Pregnant --> 7 days of nitrofurantoin; 7 days of augmentin if allergic
Case 2: 24F w/ n/v and amenorrhea x 7 weeks, previously normal cycles. No medical problems, but
smokes.
1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx ✅- - Emergency orders (before PE): none
- Exam: complete PE
- Order: beta-hCG, qualitative (serum or urine), as STAT
- Clock: advance to obtain result (positive)
- Order: transvag u/s, then routine prenatal labs: blood type and Rh type, atypical antibody titer, CBC
with diff, BMP, pap smear, UA, ucx, rubella antibodies, RPR, hep B surface antigen, HIV (ELISA),
chlamydia, prenatal vitamins, iron sulfate, folic acid, counseling (prenatal, listeria and toxo precautions,
childbirth classes, breastfeeding, quit smoking and alcohol)
- Change location to "home"
- schedule appt in 4 weeks (until week 28, then every two weeks until week 36, then every week),
review test results, pelvic u/s confirms pregnancy
- Dx: pregnancy
What is Chadwick's sign? ✅- bluish discoloration of the vulva/vagina; demonstrates pregnancy
Case 3: 28M presents to the office with one week of BRBPR and colicky abdominal pain. No sick
contacts, no recent travel, no systemic sx's. Hemodynamically stable. He has an older brother with UC,
and he is a smoker.
1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx ✅- - Emergency orders: none
,- PE: general, skin, HEENT/neck, chest/lung, CV, abdominal, rectal, extremities/spine
- Orders: CBC with diff, BMP, stool for ova and parasites, stool for white cells, stool for bacterial culture,
LFTs, PT/INR, PTT, ESR
- Location: change to "home"
- Clock: schedule appt in a week, and advance to obtain results - note elevated ESR!
- Order: sigmoidoscopy, rectal bx
- Clock: advance to obtain results - UC dx confirmed
- Location: change back to "office"
- Order: topical 5-ASA (mesalamine), loperamide, dicyclomine (antispasmodic), dietary consult,
counseling
- Location: change to "home"
- Clock: schedule appt in 2 weeks
- Final orders: none
Dx: UC, mild case involving rectum and sigmoid colon
Case 4: 26F presents to the office with lower abdominal pain, nausea, slight vag bleeding. LMP 7 weeks
ago. Sexually active. Hx of PID x 2. Afebrile, hemodynamically stable.
1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx ✅- - Emergency orders:
- PE: demonstrates LLQ abd ttp, bluish discoloration of the vulva, blood oozing from a closed os, slightly
enlarged uterus, L adnexal tenderness
- Order: urine or serum qual beta-hCG
- advance clock to "next available result" - positive upreg
- location: change to "ward"
- Order: NPO, vitals q1hr, IV access, IV normal saline, complete bedrest, quant serum beta, transvag u/s,
type and cross, blood group and Rh, CBC with diff, PT/PTT, BMP, LFTs, cervical gonococcal and chlamydia
cultures - all should be "stat"
- Clock: advance clock to see transvag u/s (tubal mass) and quant beta (2000), Rh+
- Order: OB/GYN consult, MTX, morphine
- Clock: advance to get OB recommendations
- Order: cancel "NPO, vitals, IV access, normal saline, and complete bedrest"
- Order: rest at home, counseling
- Location: change to "home"
, - Clock: appt in 4 days (for repeat serum beta)
- Final orders: none
Dx: ectopic pregnancy
When do you give MTX for an ectopic? When do you perform a lap? ✅- MTX - beta < 5000, tubal mass
< 3.5cm, no fetal cardiac activity
laparoscopy - beta > 5000, tubal mass > 3.5cm, with fetal cardiac activity
Case 5: 27F presents to the office with 3 months of alternating diarrhea and constipation, colicky
abdominal pain relieved by defecation, and 3 days of non-bloody diarrhea containing mucus. No sick
contact, no travel, no weight loss, no systemic sx's.
1. Emergency orders
2. Physical Exam
3. Diagnostic tests
4. Therapy
5. Location
6. Final order
7. Dx ✅- - Emergency orders: none
- Exam: normal
- Orders: CBC, BMP, ESR, TSH, FOBT, stool for ova/parasites/white cells/culture, 72-hr stool fat, pap
smear - all "routine"
- Location: change to "home"
- Clock: schedule appt in one week, see normal results
- Location: "office", request interval/f/u
- Order: lactose-free diet, high fiber diet, loperamide, biofeedback, reassurance, relaxation, exercise, pt
counseling, advise to drive with seat belt
- Location: change to "home"
- Clock: schedule appt in 2 weeks
- Final orders: none
Dx: IBS
Case 6: 40F presents to the office with feelings of worthlessness, fatigue, insomnia, anhedonia, poor
appetite, inability to concentrate, and feelings of guilt and hopelessness x 2 months. Sx's have forced her
to take a leave of absence from work.
