USMLE Step 3 & CCS

USMLE Step 3 exam is designed to test your medical knowledge, its application to patient care and clinical decision-making. In other words, USMLE wants to make sure you will do fine, practicing medicine independently and without supervision. Residents usually take Step 3 after their first year of medical residency (PGY 1). You must pass the Step 3 exam to complete your residency program and be eligible to get a permanent medical license. This web page guides you through USMLE Step 3 and gives you vital tips on correctly answering Computer-based Case Simulations (CCS).

USMLE Step 3 exam is given on two consecutive days (8 hours each) at a Prometric test center and has two components. On the first day, the test consists of 336 multiple-choice questions (MCQs) given in several blocks of 25 to 50 MCQs each. On the second day, 144 MCQs will be given in the first 3 hours. Over the next 4 hours you will be given nine Computer-based Case Simulations (CCS). Think of the USMLE Step 3 test as a two-day vacation, away from your medical residency program.

The majority of questions for USMLE Step 3 will be in an Outpatient/ ambulatory setting. Emergency Room (ER) and Inpatient/hospital setting will also be part of the Step 3 exam. The test content will closely reflect the common diseases seen in your medical residency training. Internal Medicine will consist of approximately, 60% of questions. If you are not an Internal Medicine or Family practice Resident, please devote 90 % of your preparation time on Internal Medicine. OBGYN, Pediatrics and Surgery will account for approximately 10 % each. Psychiatry, Medical Ethics and other content will account for the rest.

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When preparing for USMLE Step 3, special attention should be given to … 

ü Screening tests- Fecal occult blood, Rectal exam, Colonoscopy / Sigmoidoscopy, Mammogram, Breast exam, Pelvic exam, Pap smear, PSA, and Prostate exam.

ü Clinical guidelines and age at which to initiate the above measures, Pneumococcal and influenza vaccination, meningococcal vaccine (e.g. military recruits). These are the same guidelines that you follow in your residency program.

ü Side effects of common medications are a favorite topic for USMLE Step 3 questions (e.g. statins-muscle pain/ Rhabdomyolysis).

ü Depression, anxiety, bipolar, hyponatremia, Marfan’s, child abuse, vaginal bleeding, STD, Vaginal infections, PID, eclampsia, Hypertension, Diabetes, MI, CHF, chest pain work up- exercise treadmill, cardiolyte / Thallium scan, Stress echo etc.  

Here are some tips to help you with the USMLE CCS exam… 

  • Pay close attention to the setting (location) of the patient encounter. The setting helps you decide on the aggressiveness of your treatment orders and whether to send the patient home. It also gives a clue to the medical diagnosis.

  • If the setting is ER and you are not sure of the medical diagnosis, admit the patient and work him up. You can always discharge him from the hospital, the next day. USMLE Step 3 CCS is testing you to see if you practice safe medicine. One year of medical residency should help you in your decision making.

  • Write down the age, sex, chief complaint, and allergies of the patient on the writing sheet provided at the exam. This will help you save time when considering medical differential diagnosis.

  • Counseling is a major part of outpatient office visits. Pay particular attention to counseling in normal/ routine patient visits. This is similar to real counseling provided by you in your medical residency.

  • Important counseling topics include smoking, alcohol, drugs, safe sex practices, exercise, weight reduction, diet, and self-breast exam. You can score points for these orders in the USMLE Step 3 CCS test. 

  • If the patient presents with breathing difficulty, remember to order Oxygen, albuterol PRN and hook him up with a pulse oximetry.

  • Patients presenting to the ER in an unresponsive state should have a finger stick glucose done with a glucometer stat, naloxone given if opiates are suspected (Pupils), and thiamine added to IV fluids if alcoholic.

  • Patients with Hypertension and diabetes should have appropriate diets ordered (2 gm salt restricted or 1800 ADA diet)

  • For abnormal LFTs order a hepatitis profile/panel if appropriate. USMLE CCS exam assesses the appropriateness of medical orders.

  • Order tests to diagnose H. pylori if patient has GERD. The H. pylori antibody should be ordered if the patient has never been diagnosed before and the Urease breath test if checking for elimination/ recurrence.

  • Overdose/poisoning patients should be admitted to the ICU for closer monitoring and suicide precautions. Don’t forget to get a Psychiatry consult.

  • Inpatient hospital admissions need a physical exam everyday and appropriate lab and medical orders. Remember what you do daily in your residency, and you will be fine. 

  • When writing orders, you can save time by holding down “control” and selecting multiple orders with your mouse.

  • Acute abdomen and most surgical emergencies need frequent and multiple interval H&P.

·         Don’t forget to advance the clock during the USMLE Step 3 CCS exam. Remember, you will not get results and nothing will happen until you advance the clock.

·         Get appropriate consults. You will get credit for this. However, once you ask for a consult, the computer may ask you to manage it yourself temporarily, as the consultant is busy. Don’t worry. Do the routine pre-op stuff and stabilize the patient.

·         Use keywords to get order lists- “Stop, Avoid, Diet, Vaccine, Advice” etc 

·         Have a routine scheme / checklist to follow for USMLE CCS exam. This avoids overlooking common orders. You can even write down this checklist on the writing sheet provided at the USMLE testing center. You can then rapidly refer to the checklist and make sure that you have not forgotten anything.

·         In the ER, first do a brief physical exam (2 min). Then write orders and labs. Once the patient is stabilized and lab results reviewed, do a full physical exam. Then shift the patient to the ICU or ward.

·         Remember… First stabilize, then full physical, and then admit. This is also what you would do, in your residency training and real life.

·         When ordering labs in the ER, avoid asking for panels (e.g. CMP or BMP), The results will be delayed. Instead order the individual components of the panel. You can order panels in other settings.  

USMLE CCS Checklist 

  1. Labs:

ü CBC, CMP, Urine routine, TSH, Lipid Profile, Cardiac enzymes, ABG, Glucometer check, Drug levels, Toxicology screen-Urine and serum, ANA, ESR.

ü Bleeding & pre-op pts– Type Blood and cross match, PT/INR, PTT.

ü Infections – cultures of Blood, Urine, Sputum or CSF, as appropriate.

ü Acute abdomen – order amylase, lipase, b HCG & acute abdominal X ray series. 

  1. Imaging & EKG

ü EKG, EEG, Echo, Ultrasound, Carotid Doppler

ü CXR, X ray Joints, acute abdominal series

ü CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.  

  1. Nursing orders

ü NPO, Diet, IV Fluids, Vitals, Input/output, Physical therapy

ü Tubes- NG, Foley

ü Pulse oximetry & Oxygen, cardiac monitor 

  1. Medication orders 

  1. Counseling

ü Weight loss, exercise, diet, smoking & alcohol cessation. 

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