z******8
发帖数: 844 | 1 ☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 00:13:42 2014, 美东) 提到:
Step3考场壮烈回来。第一天挺累人，最后一个block甚至做到有心无力状，看着题反应
不过来，导致来不及做完。非常没有信心能否通过。所以match之前先考Step3的童鞋，
需要考前调整生物钟，坚持锻炼，提高耐力。
MCQ没有资格说，CCS有一点小感受，拿出来分享下。大家请轻拍砖。
复习资料：
UW 52 online cases : 基础。最好复习早起找高手一起过一遍，尽快摸熟软件，进入
状态。第二遍找一位水平相近童鞋过一遍，不断总结protocol. 考前迅速做一遍，熟练
运用protocol.
UW 41 offline cases: 我当时和partner每个case仔细做一遍，虽然不像online有反馈
，但对练临床思维，补充protocol非常有帮助。最后考试与41 case有异曲同工之处，
遇到复杂case也不慌神。
CD 6 cases： 最后再熟悉下考试软件。与UW相近，但更有效更人性化。比如ER 所有
diagnostic test直接设置为STAT。
Experience:
1. Mnemonic：
what＇s to be managed？
V: abnormal vitals
A: age
S: sex
C: chief complaint
O: other symptoms to be managed (eg, N&V, pain, etc)
D: Disease (PMH)
A: Allergy (do not order these meds afterwards)
L: Lifestyle to be modified (eg, smoking/alcohol/drug, etc)
http://www.mitbbs.com/pc/pccon_2289_85519.html
2. http://www.mitbbs.com/article_t2/MedicalCareer/31562703.html
3. Neeraj’s CCS notes: 尤其4 steps及最后100 Golden Rules， 补充到
protocol
考后感想：
A. 真实考试case比较复杂。体现在两点：
a. 主诉insidious，不要assume Dx! 比如单侧肩痛要考虑到肺尖瘤压迫。需要全面
考虑DDx.
b. Initial history提供各种RF，在诊断中都要体现。
B. 个人感觉一旦consult，可能就会force out. 与UW不同的是，consult对头会给
出阳性回应，例如拉去手术。当然， 小病也给consult，别人不屑，结果自负。
C. PE很重要，在不能assume Dx时可以提供很多信息，帮助指导Dx direction.
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 00:20:46 2014, 美东) 提到:
My CCS protocol:
P.S.：多有重复，谨防遗漏，仅供参考。
Screening test: General—Lipid profile/ multi-vitamin; Elderly—DEXA scan&
Calcium& VitD/ Colonscopy or FOBT/ vaccination; F-- >18yo Pap smear; >50yo
Mammogram; reproductive age- folate; menopause- Lipid/DEXA/FOBT; M-- >50yo
PSA; sickle cell dz child-prophylaxis w penicillin till 5yo, CF-prophylaxis
w Abx
Prophylaxis: Pantoprazole, pneumatic compression stocking;
Acute abd w perforation: triple Abx- Gentamycin/ Ampicillin/
Metronidazole (口诀：阿扁举旗庆国庆)
ER orders:IV access, NS, oxygen, pulse oximetry, cardiac monitor, BP monitor
, 12 lead EKG
Post-trauma: Cervical immobilization.
Chest pain: EKG (aspirin& nitrite)
AMS: ER order-- Glucometer, NPO& bedrest, head elevation& aspiration
precaution; naloxone& dextrose& thiamine& O2; WU: CBC, glucometer,
electrolyte (Ca/Mg/P), UTox, serum alcohol, CXR (exclude aspiration)
PE: office complete PE, but in sick pt-> focused PE
ER focused PE-> complete PE after stable
Routine: CBC, BMP, EKG, CXR, UA (If elderly/abnormal LFT/lipid, add TSH; in
young F, add beta-hCG)
Respiratory special: head elevation& aspiration precaution& Nasotracheal
suction, PEFR (in asthma& COPD), pulse oximetry if low PaO2-> ABG, CXR;
oxygen, humidified air, albuterol inhaler if necessary; vaccine-Influenza&
Pneumococcal, smoking cessation, chest physiotherapy (large amount of
secretions);
Cardiac: Cardiac /BP mornitor, Aspirin& SL Nitrite, EKG, Echocardiogram,
cardiac enzyme, lipid profile, bed rest. Low-salt/low fat diet.
Neuro: Head CT, MRI brain; vascular prob: carotid Doppler, MRA brain, CEA-
endarterectomy (TIA)~, if consider cardiac cause-EKG/holter monitor->
warfarin for AFib.
Dementia: rule out reversible causes first (TSH, Vitamin B12&
folate level, head CT, VDRL& RPR+ routine order), rule out depression
GI: PE-abd, rectal; XRay abd, US abd, LFT, (amylase, lipase, beta hCG-F,
FOBT)+imaging test (Xray abd, US abd, CT abd, ERCP& GI consult, EGD& GI
consult)
Upper GI distress: consider bowel rest (NPO/ NG tube/ IV NSS/ PPI
prophylaxis); head elevation&NG suction& aspiration precautions (at risk of
aspiration); if peritonitis exist- Abx (cipro+ Mitronidazole)
IV ABx: Tx for G neg & anaerobics—Piperacillin-tazobactam/
ceftriaxone+ metronidazone
ID: CBC, Blood Cx, urine Cx, ESR, PT/PTT; Spurum Cx, stool Cx, cervical
dischage Cx
bacteria-Cx/serology; virus-PCR
Monitor: CBC, BMP, ESR
STD: cervical discharge- pH&KOH prep& wet mount, gram stain, G&C Cx; HIV (
ELISA)& Syphillis test (VDRL, RPR); UA, Urine Cx; Pap smear; counseling-
treat partner; if vaginal candida (fungus infection)-> check glucometer
Hematology:
Microcytic anemia w unknown cause: do iron study (iron/ferritin/
TIBC)
Active bleeding pt: PT/PTT, BT, blood type& crossing-> in case to
OR-> counseling no aspirin/contact sport
Bleeding diathesis (CBC, BMP, LFT, PT/PTT, BT, blood type&
crossing-> plasma Factor VIII, IX, XI, vWF); send to ER/ward; Tx w Factor_+
desmopressin& Aminocaproic acid; monitor with PTT/factor_ ; counseling No
aspirin/ contact sport/family /(consult genetics);
Jaundice: PT/PTT/LFT/BT, Coombs, bilirubin/LDH/Hepatoglobin/
reticulocyte, blood type/Rh
Psycho: WU-Utox/ serum alcohol/TSH. Tx-Consult psychiatry/ suicide contract&
suicide precautions (depression/mania)/ psychotherapy(biofeedback)
Disease caused by stress: reassurance/ relaxation/ biofeedback
Acute mania Tx: olanzaping/Risperidone IM, Lithium oral.
Child abuse: Child protection services/ consult ophthalmology& psychiatrist
Neuro-menigitis/encephalitis Dx& Tx sequence:
Blood Cx+ Head CT-> Antibiotics-> LP (cell count/glucose/protein/gram
stain/C&S/ bacterial Ag test/ indian ink/Acid Fast/HSV PCR)
Rheumatology: DDx- ANA/RF/TSH/ ESR/ CPK; monitor with ESR& CBC
OB/GYN: vaginal bleeding DDx-- beta-hCG/TSH/prolactin+ CBC+PT/PTT/LFT+ pap
smear+ US pelvic
Pregnancy order: beta-hCG “stat”-> US transvaginal
Blood type&Rh/ atypical Ab titer/CBC,BMP, UA& urine Cx
Pap smear/ TORCH (HIV-ELISA/Rubella Ab/RPR/HBsAg/Chla&Gono)
Prenatal Vitamin/iron/folic acid/prenatal counseling…
F/U: 4wk until 28wk, 2wk 28-36wk, 1wk 36wk-delivery
MVA: ER-cervical immobilization/ Foley& urine output; complete PE
Dx: MVA-skeletal survey (Xray neck, Xray pelvic), UTox& serum alcohol;
pre-op- PT/PTT, blood type& crossing, consult surgery, NPO; +specific Dx (
Abd: stable- CT abd; unstable- US abd)
DM: glucometer (Q8h), HbA1C; ward order: DM diet; counseling DM diet/home
glucose monitor/consult ophthalmology/foot care/
DM in-patient: glucometer& HBA1C, D/C oral hypoglycemic agents&
start insulin, strict glycemic control
DKA: Ca&P&Mg/ ABG/ Serum osmolarity/serum ketone)-> Tx: insulin
regular IV+ supportive Tx-> admit to ICU-> Tx: KCl+ P, monitor (BMP& ABG
Q2hr)
Alcoholic ketoacidosis: Dx test similar to DKA, Tx: dextrose+ NSS
+ thiamine
OD (overdose): NG tube& gastric lavage+ activated charcoal (unless AMS& risk
for aspiration)+ antidote; CXR (exclude aspiration)
HTN: BP monitor; BP control
HIV: ELISA-> Western Blot+ CD4+ viral load-> Tx: Lamivudin+Zidovudin+Efavir;
counseling safe sex/ HIV support group;
In HIV pt w headache: consider cryptococcal/TB/Toxoplasmasis/ CNS
lymphoma; PCP if chest pain or SOB.
Surgery preparation: NPO (NG tube-abd), PT/PTT/INR, blood type & crossing,
Preoperation antibiotics—Cefoxitin/Cefzolin, Morphine, Surgery consult+
pneumatic compression stocking/foley/ urine output
Procedure& Fluid analysis: order PT/PTT first!
Synovial fluid: “3C” Cell count/ glucose/ viscosity; Crystal; gram stain/
C&S
Vaginal discharge: vaginal pH/ KOH prep/ wet mount; G&C; C&S/ fungus Cx;
check other STD- HIV/PRP/ pap smear
Thoracocentesis: LDH& protein; serum LDH& protein
CSF: cell count/protein/glucose; gram stain/C&S/fast stain &TB culture/
Indian ink& crytococccal Cx(HIV)/ virus PCR (encephalitis)
Stool: fat stain/ cell count/ gram stain/ C&S/ O&P
Sputum: gram stain/C&S/ fast stain
Ward order: NPO& urine output, complete bed rest& pneumatic compression
stocking; or special diet (DM-DM diet, HTN- low salt& low fat diet, hepatic
failure-low protein, IBS- high fiber diet, HF-water restriction…), ambulate
at will
ICU order: NPO, complete bed rest, urine output, foley catheter,
pantoprazole
Supportive Tx: Vomiting-Phenergan IV, Metoclopromide oral
Analgesics& antipyretics- Percocet (acetaminophen+
ketoralac)IV/Oral
Severe smatic pain: Morphine IV/oral (except CBD stone-
> Mepiridine IV)
Severe body pain: Naprexone/ Ketorolac (NSAID) oral
Chest pain: Aspirin oral+Nitrite SL (subligual)
Decongestant-Psudoephedrine topical
Diarrhea- Loperamide
Costipation-Psyllium->Docusate
Spasm-dicyclomine (post-surgery abd pain)
Insomnia-benzodiazepine/ diazepam
Statin- Simvastatin; AntiCholinergic (AD)-Donepezil; ACEI-Lisinopril; CCB-
Nimodipine; Hemophilia med- Aminocaproic acid+ desmopressin+Factor; LMWH-
Lovenox; Hemicolectomy (colon cancer resection)
Specific& critical meds:
1. AD- Donepezil& Vitamin E; if agitation- olanzapine/haloperidol
2. Afib: first rate control- diltiazem/metoprolol, then consider
anticoagulation
3. Complete heart block/ M-II: transcutaneous pacemaker-> transvenous
pacemaker-> permanent inserted pacemaker
4. MDD- fluoxetine; Anxiety-buspirone
5. COPD exacerbation-Albuteral& Ipratropium nebulizer+ (severe)
prednisone IV+ Abx prophylaxis (ceftriaxone& azithromycin)+ (PCO2>45/pH>7.3)
mechanical ventilation-> chest PT+ vaccine
6. Symptomatic palpitation: Holter monitor
First-time panic attack: check UTOX, TSH, glucometer, EKG& cardiac enzyme
Tx: Alprazolam (acute)-> Fluoxetine (long-term)/no caffeine
7. Child <3wk w fever: consider sepsis unless otherwise-> transfer to
ward& Cx.
8. Hyperthyroidism w exophthalmos: thyroid meds+ prednisone
9. Stroke/TIA meds: Aspirin-> Clopidogrel/ Dipyridamole
10. Bleeding diathesis: Factor_+ desmopressin& Aminocaproic acid; consult
genetics
11. Unstable Angina: ER order- Aspirin oral, Nitroglycerin SL
WU order- metoprolol IV; Pre-op- abciximab IV-> cardiac catheterization&
angioplasty
D/C meds- aspirin/metoprolol/Simvastatin/ nitroglycerin/ clopidogrel
Med SE prophylaxis:
a. Steroid use in elderly: Prednisone oral; Dexamethasone/
methylprednisone IV
Complication prophylaxis: Pantoprazone (PPI), VitD& Calcium&
alendronate (osteophorosis); monitor with DEXA scan
b. Before using TMP-SMX, check G6PD/beta-hCG
c. Furosemide use: also add NSS& KCl
d. Heparin: FOBT-> heparin, monitor platelet on D3& D5(every other day)+
H&H
Warfarin: monitor PT/INR QD for 2d till within therapeutic range (2~3)
e. Gentamycin to children: monitor hearing test& BUN/Cr
f. Lithium/Theophylline: check drug level
g. Pt taking beta-blocker that requires Epi: give glucagon first!
h. TB meds: IHN& Vit B6; Pyrazinamide-order serum uric acid; Ethabutol-
consult ophthalmology
i. Prednisone to child: first get PPD.
Clinical tricks: a. before anti-HTN med- head CT to exclude hemorrhage
b. Aneurysm rupture/active bleeding- D/C HTN med&
aspirin
c. Meningitis Dx& Tx sequence: Blood Cx+ Head CT->
Antibiotics-> LP
d. CXR shows an effusion: order CXR decubitus
e. Intubate a pt: also order mechanical
ventilation
f. Major procedure (surgery/-scopy& Bx/ -centesis)
g. If vaginal candida (fungus infection)-> check
glucometer
h. Take EKG& CXR before Echocardiogram
i. Before starting estrogen replacement, should check serum FSH& LH
levels.
Counseling: terminal dz: counseling advanced directives
Chronic dz-> future AMS: medical alert bracelet
Dementia& alcoholic pt: no driving
AD: physical therapy/consult social worker/medical alert bracelet
/no driving/advanced directive/safety plan
Bleeding: no aspirin/ no contact sports
DM pt: foot care/ consult ophthalmology/ home gluc monitor/ DM
diet/med
Acute gout: Diet low protein, no alcohol/ aspirin/ med
Time management: Chronic dz: initial Dx test-> appointment 1wk; Tx order->
appointment 2wk (infection) to 1mo (MDD/IDA)/6wk (AD/benign breast lump
after FNA)
ER: ER order &PE->initial order->advance by 30mins; rountine order& Tx->
advance by 4hrs.
If pt in acute distress w stable VS@ office: after focused PE, directly send
to ward/ER/ICU, then WU
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rhcrc11 (Rebel) 于 (Thu May 15 00:26:56 2014, 美东) 提到:
还有部分Abx总结，以前有经验贴分享USMLEforum的经典贴。但自己总结的东西容易记
住。希望给大家一点帮助。
P.S.: 顺着iamreallybad&斑竹思路，旁注中文为mnemonics.
Menigitis: G- use Ceftriaxone; bacilli use Gentamycin; DXM- in S. pneumonia
& unknown microb infection
G+ cocci: Vancomycin+Ceftriaxon
G+ bacilli (Listeria): Ampicillin + Gentamycin +
dexamethasone
G- cocci: Ceftriaxon
G- bacilli: Ceftriaxon+ Gentamycin
Fungus: Amphotericin+ Flucytosin IV-> Fluconazole oral
Virus encephalitis: Acyclovir
Septic arthritis:
Broad-spectrum coverage: Ceftriaxone+ vancomycin
G+ cocci: MRSA- Vancomycin IV 4~6wk;
MSSA Nafcillin/Cefazolin IV 2wk-> oral 2
~4wk
G- bacilli: Ceftriaxone IV 2wk-> oral 2wk
Cellulitis:
Mild: Purulent: MRSA suspected- Clindamycin/ TMP-SMX/ Doxycycline/
Linezolid
Nonpurulent: Strep beta hemolytic& MSSA- Clindamycin/
Amoxicillin+TMP-SMX/ Amoxicillin+ Doxycycline/ Linezolid 1wk
Severe: Hospitalize-> Vancomycin IV 2wk
Infectious diarrhea: Bactrim started empirically; G- bacteria: erythromycin,
Parasite: metronidazole
Campylobacter jejuni-erythromycin;
C difficile colitis: metronidazole;
Systemic salmonellosis: fluoroquinolones/azithromycin/ third
generation cephalosporins such as ceftriaxone or cefotaxime.
Giardia: metronidazole, furazolidone, or quinacrine, for example.
Febrile Neutropenia 2/2 chemotherapy Tx:
Empiric: Cefepime/Meropenem/Aminoglycoside+TCP penecillin
Vancomycin indication: no response after 3d monotherapy; pt presents with
hypotension, mucositis, skin or catheter site infection, h/o MRSA
colonization, or recent quinolone prophylaxis (Abx resistence).
Caspofungin indication: 7d of neutropenia in patients with persistent fever.
G-CSF indication: pts with predictive poor outcome such as patients with ANC
<100/μL, uncontrolled primary disease, pneumonia, hypotension, multiorgan
dysfunction, or invasive fungal infection.
Pt becomes afebrile in 3d, change to oral Abx (cefixime/ quinolone).
Pt is still febrile after 3d, add vancomycin, repeat Cx, and CXR.
Uncomplicated neutropenia: 7d Abx; complicated (afebrile& ANC<500): continue
Abx till normal findings.
Infectious Endocarditis: sym-multiple petechiae (septic embolism)+high fever
+ high RF (IV drug abuse)
Tx: empiric- Vancomycin (G+)+ Gentamicin (G-) IV
If Cx is sensitive S. aureus: Nafcillin IV for 4-6wks
Pneumonia Tx: need to cover S. pneumonia, E. coli, legionella
CAP/OP: FQ (levofloxacin/moxifloxacin)/ macrolide (Azithromycin) “福虹”
HAP/IP: FQ/ Ceftriaxone+ Azithromycin “斧头红”
Same as COPD exacerbation Abx prophylaxis
Pediatric PNA:
OP/mild: Amoxicillin/ cefuroxime “阿头”
IP/severe: Cefuroxime +- Vancomycin (cover S. aureus) “万头红”
Chlamydia/mycoplasma: erythromycin
CF Abx prophylaxis:
Mild: FQs/macrolide/ TMP-SMX “扶红梯”
If w Pseudomonas/S. aureus infection: Piperacillin+ Cefempine
Resistant: inhaled Tobramycin
UTI& STD Tx:
Cystitis: TMP-SMX/Ciprofloxacin
Pyelonephritis: Ciprofloxacin oral; ampicillin/gentamicin IV
Prostitis: Ciprofloxacin/ TMP-SMX oral, 6~12wk
Pregnancy 奈阿头(nifutriatonin, )； 庆头
PID:
Hospitalization: IV Cefotetan+ IV Doxycycline
Outpatient: IM (one dose) Ceftriaxone+ PO Doxycycline x14d
Post-partum Endometritis: cover broad spectrum of anaerobes& aerobics: 庆林-
Gentamycin+Clindamycin
TSS (toxic shock syn): 1. Remove precipitating factor (tampon removal+
tampon C&S); 2. Vancomycin/Clindamycin IV->oral; 3. Reassurance
Acute abd with suspected/proved perforation: triple Abx- Gentamycin/
Ampicillin/ Metronidazole (G-, G+, anaerobic) 阿扁举旗庆国庆
☆─────────────────────────────────────☆
Springsteen (The Rising) 于 (Thu May 15 00:28:44 2014, 美东) 提到:
谢谢分享。
☆─────────────────────────────────────☆
hygia (猪猪) 于 (Thu May 15 01:36:08 2014, 美东) 提到:
谢谢分享！！
恭喜考完，预祝拿到好成绩！！
☆─────────────────────────────────────☆
iamreallybad (我是Jeff) 于 (Thu May 15 08:19:58 2014, 美东) 提到:
恭喜考完step3！
Lele同学的热心和乐于助人是大家都知道的。
☆─────────────────────────────────────☆
zhu84518 (Henry) 于 (Thu May 15 08:23:30 2014, 美东) 提到:
恭喜考完哈，谢谢分享，包子奉上
☆─────────────────────────────────────☆
tina31 (tina) 于 (Thu May 15 08:34:46 2014, 美东) 提到:
Thank you very much for sharing your experience and protocols.
☆─────────────────────────────────────☆
molsoncheng (molsoncheng) 于 (Thu May 15 09:49:38 2014, 美东) 提到:
Totally agree with you. The first day long blocks are really difficult to me
while ok with the 4 short blocks and CCS on second day. Unfortunately I
even do not know how to be more prepared if fail this test.
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 11:23:52 2014, 美东) 提到:
谢谢大清早给包子，正好中午留着吃:D
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 11:31:13 2014, 美东) 提到:
彼此彼此啦～～这些年幸会一帮很好的学习伙伴，以后有空继续交流哈:)
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Thu May 15 11:34:22 2014, 美东) 提到:
It's a good thing that we all survived from the tough 2d exam!
No idea at the moment, but wish for the best!
me
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panda22 (胖滴) 于 (Thu May 15 12:32:14 2014, 美东) 提到:
祝贺顺利考完！step3考个高分不易，但pass没问题，尤其没有match困扰。
一直觉得你是一个善良热心的童鞋，很荣幸与你同乘2014病理新船！
☆─────────────────────────────────────☆
negitla (温柔的灌) 于 (Thu May 15 13:14:58 2014, 美东) 提到:
恭喜考完，预祝拿到好成绩！美女你太热心了，赞
☆─────────────────────────────────────☆
Blueshine (Blueshine) 于 (Thu May 15 14:34:17 2014, 美东) 提到:
大赞！非常详细的考经啊，恭喜有好成绩！
☆─────────────────────────────────────☆
HoneyAB (AB) 于 (Thu May 15 23:32:19 2014, 美东) 提到:
十万分感谢！祝一切顺利！
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Fri May 16 14:59:40 2014, 美东) 提到:
欢迎参加我们新intern学习小组！
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rhcrc11 (Rebel) 于 (Fri May 16 15:00:39 2014, 美东) 提到:
谢谢一路有你同行:)
☆─────────────────────────────────────☆
rhcrc11 (Rebel) 于 (Fri May 16 15:01:24 2014, 美东) 提到:
也祝考试顺利！ | f**********d
发帖数: 231 | 2 恭喜lele考完！
【在 z******8 的大作中提到】
: ☆─────────────────────────────────────☆
: rhcrc11 (Rebel) 于 (Thu May 15 00:13:42 2014, 美东) 提到:
: Step3考场壮烈回来。第一天挺累人，最后一个block甚至做到有心无力状，看着题反应
: 不过来，导致来不及做完。非常没有信心能否通过。所以match之前先考Step3的童鞋，
: 需要考前调整生物钟，坚持锻炼，提高耐力。
: MCQ没有资格说，CCS有一点小感受，拿出来分享下。大家请轻拍砖。
: 复习资料：
: UW 52 online cases : 基础。最好复习早起找高手一起过一遍，尽快摸熟软件，进入
: 状态。第二遍找一位水平相近童鞋过一遍，不断总结protocol. 考前迅速做一遍，熟练
: 运用protocol.
|
|
