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 Step by Step approach to CCS Cases  

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Step by step guide to CCS cases: I don't know if this has been posted before, I found it on the net and it should make the CCS cases easier to approach.

Select 'Start Case' button to begin.

You will see the case introduction. Wait! Note on the erasable board:

Age of the patient
Race of the Patient
Sex of the patient

Then click 'OK' and you will see the initial vital signs. Wait! Note on the erasable board:

Stable or unstable?

Then click 'OK' and you will see the initial history. Wait! Think and write on the erasable board:

Differential Diagnosis :
Habits – smoking , alcohol , drugs , etc. Anything worrisome?

Then ask:

Is the patient stable or is it an emergency? A clue to this would be in the history - for emergency cases, you will see only the basic history of present illness and not the detailed history (social, past, etc). All other history will be 'unobtainable'.

If unstable, do a EMERGENT physical exam. No emergency case should get a full physical exam - it's an emergency!!

For the EMERGENT physical, choose the 'general appearance' and the relevant system. If needed, add one or two relevant systems.

After you note the results of the EMERGENT physical, stabilize patient immediately:

Airway – Intubation?
Breathing – Oxygen mask? Chest tube?
Circulation – IV fluids? Dopamine?
Drugs – Naloxone? Dextrose? Thiamine?
IV Access?

Then ask:

Does the patient's condition correlate to the setting?

Emergency or unstable patient in office needs to go to the ER immediately!! Change location if necessary.

After the patient is stable and in the right setting, proceed to 'Interval/follow-up history' and a more detailed RELEVANT physical exam.

If the patient is already a stable case in the right setting, proceed straight to the RELEVANT physical exam.

Then ask:

Is the case limited to one particular system? Like Asthma or MI?

Choose the particular system and a few related systems, based on the most likely diagnosis.

Is the case not limited to one particular system?

Choose a COMPLETE physical exam. This option is available on the top of the physical exam choices. Examples of such cases include Case for Annual Physical Exam, Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc.

Note the significant findings on the physical exam and go back to your erasable paper and revise your Differential Diagnosis. Strike out those which are less likely and add those are more likely.

Then keeping the Differential Diagnosis in mind, consider the labs to be done.

When considering labs use this mnemonic:


I – Imaging –> X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.

B – Blood –> CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.

U – Urine –> Urinalysis, Toxicology Screen, Ketones, etc.

O – Others –> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse Oximetry, Biopsies, etc.

P – Pregnancy test –> For any female of reproductive age presenting with abdominal or pelvic symptoms, or trauma.

When ordering labs, consider:

Is this test time-effective/time-consuming? Choose time-effective.

Is this test initial screening/confirmatory? Choose initial screening.

Is this test cheap/expensive? Choose cheap.

Is this test non-invasive/invasive? Choose non-invasive.

Then ask:

Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the above criteria but will not tell you anything useful.

Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat Chloride test for Cystic Fibrosis, etc.

Are the tests in the right order? Example – Pulse Oximetry before ABG, CT before Spinal Tap, etc.

Order the labs using the Order button.

Then advance clock to the 'Next Available Result'.

Understand the results. Ask:

Is the diagnosis clear or do I need any confirmatory tests?

If diagnosis is clear, start treatment.

If confirmation is needed, order confirmatory tests and then start treatment.

Treatment :

Determine if the patient is in the right setting. If patient is in office and needs to be admitted, change location to ward. If patient is in ward and is in a serious condition, change location to ICU.

If case is admitted, order:

IV access (unless IV drugs are not indicated) – Type 'IV Access'.

Vital Signs – Type Vitals and click on 'Every 1,2, 4 or 6 hours' depending on the condition of patient.

Activity – Type 'Bed Rest' and choose 'Complete bed rest' or 'Bed rest with bathroom privileges' or type restrain and choose 'Restrain patient in bed'.

Diet – Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order 'Diet' and you will see the list of options, choose which is the best for this case.

Tubes – NG Tube? Foley's catheter?

Fluids – Saline, Ringer, etc. Type 'Fluids' and choose which is the best for this case.

Urine output – Type 'Urine Output' and choose frequency. There is no option for Input/output chart.

Medications :

Stop! Check for allergies on erasable board!

Order standard drugs for this case.

Decide IV or Oral. Decide bolus or continuous. Decide frequency.

Labs :

Additional labs to confirm diagnosis?

Labs to monitor? Cardiac Monitor? Pulse Oximetry?

Consults :

Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.

Then move clock!

Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1 week.

Do Interval/follow-up history.

Understand the results of the labs.

Then ask:

Has the patient's condition changed significantly?

If yes, change locations.

If the condition has improved, move the patient to the next location in the order ER --> ICU --> Ward --> Office/Home.

If the condition has worsened, move the patient to the next location in the order Home/Office --> Ward/ER or Ward/ER --> ICU.

If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home):

Stop unnecessary medications and change IV medications to oral.
Discontinue IV fluids.
Remove tubes.
Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant.
Patient education or counseling or diet specific and vital to this case. Type 'patient education' and 'counsel' and see if anything is relevant to this specific case. Type 'Diet' and see if anything is relevant to this specific case.

By this time, the 5 minute screen will appear!

Then type 'counsel' and choose the relevant things. You can choose multiple things at a time. See your erasable board for any worrisome habits like alcohol or smoking!

Type 'patient education' and choose the relevant things. You can choose multiple things at a time.

Patient education / Counseling options :

Every adult person - Drive with seat belt, Exercise program, No illegal drug use.

Every person taking long-term medications - Medication compliance, Side effects of medication.

Every person who takes alcohol - Limit or stop alcohol intake.

Every person who smokes - Smoking cessation.

Every person of reproductive capacity - Safe sex techniques.

Every person with long-term conditions, life-threatening allergies, chronic illnesses - Medic Alert Bracelet.

Female requesting contraception or practicing unsafe sex - Birth control, Contraception, Safe sex techniques.

Cancer case - Cancer diagnosis.

Asthmatic - Asthma care, medication compliance.

Terminal case - Advance Directive (Family), Advance Directive (Patient) and Living will.

Every post-operative case - Deep breathing and coughing

Diabetic - Diabetic foot care, Home glucose monitoring, Diet.

Learning disorder kid - Educational remediation.

Osteoporosis - Estrogen replacement therapy.

HIV case - HIV support group, safe sex techniques.

Hypothyroidism or endocrine case - Hormone replacement therapy.

Lactose intolerance - Limit cow's milk intake, Diet.

GI bleeding, peptic ulcer case - No aspirin, Sit upright after meals.

Old age, epileptic, vision defects, narcolepsy - No driving.

Anxiety case - Relaxation techniques, Rebreathing into a paper bag.

Violent psychotic case - Restraining order.

Spousal Abuse - Safety plan.

IV drug use - No illegal drug use, SBE prophylaxis, Safe sex techniques, Stop alcohol, Smoking cessation.

Pelvic surgery - No intercourse.

STD - Safe sex techniques, Sexual partner needs treatment.

Depression - Suicide contract.

Routine screening : Schedule appropriate screening tests as per age. Type the relevant test and schedule.

Immunizations : For Pediatrics and Geriatrics as relevant. Type 'Vaccine', choose and schedule.

At the end of the 5 minutes:

Type the Final Diagnosis.

You are done!!!

For Kids: Add age appropriate vaxine.
Helmets when Bicycle riding.
water temp<120 degree.
Dental health.
GUn safety.
smoke detector.
Teenage : DOnt drink while drive counsel.
For every one add age appropriate SCREEN.UV protection .Postexposure prophylaxis.
CANCER screen everyone gets it.

Females: think if she neeeds to be PAPed.
Chlamydia screen for a sexualy active with many.
Elderly geriatic *Mamograph if older.
*osteoporosis screen.
*pneumovax and flu vax for elderly.
*elderly fall prevention.
*Hormone replacement.

Screening :


Self-breast exam every month after age 20.
Clinical breast exam every year after 40.
Mammography every year after 50 in normal-risk females.
Mammography every year after 40 in high-risk females.

Pap smear - every year (for 3 years) after 18 years or earlier if sexually active. Then, every 3 years until 65.

FOBT every year after 50 + Sigmoidoscopy every 3 years after 50 years.
Colonoscopy every 10 years after 50 years.

Digital Rectal Exam every year after 40.
PSA every year after 50.

Vaccines :

Geriatrics :

Pneumococcal vaccine once for every person above 65. High-risk patients get earlier.
Influenza vaccine every year for every person above 65. High-risk patients get earlier.

Pediatrics :

DTaP - 2 months, 4 months, 6 months, between 15 and 18 months, between 4 and 6 years.
IPV - 2 months, 4 months, between 6 and 18 months, between 4 and 6 years.
Hepatitis B - Birth, 2 months, 4 months.
H. influenza B - 2 months, 4 months, 6 months, 12 to 15 months.
Pneumococcus - 2 months, 4 months, 6 months, 12 to 15 months.
Varicella - Between 12 and 15 months.
MMR - Between 12 and 18 months.


I'm just going to start Step 3, looks very useful, thanks! smiling face


`for emergency cases, stabilise, then do a brief physical exam!


That was really helpful. Thanks


thats really helpful


Hey Nisha


thats very helpful




just added this post to my favorite folder, ll need a quick review later on


Very useful! Thank you smiling face nisha


Your very welcome smiling face


WOnderfull Post Nisha.........DO tell me Is the erasable board big enough.

Did u do a lot of Mock exams with UW , step123 and did u have a friend who helped you out.

Is online Dicussion needed for this ccs cases.




reaallly helpful...thank u...hv jus started preparing fr step 3...will keep bugging u wid questions...thank u soooo much smiling face


This is awesome, I'm taking step3 tomorrow and this is just in time!!!!! Thanks for putting so much work into it!


A very helpfull post. Thankyou Nisha for this hard work.


Really usefull, do you guys have any advice for me, my exam is in TWO DAYS!!!
Also, what is this Interval/Follow up history for, I am using it, but don t know its significance.

Thanks for your response
Wish me good luck




thanks dr nisha.

u r a good teacher and doctor

good luck



thanks for the time you devoted to let us know and learn


wow. just found this thread. wonderful, wonderful. thanks nisha!


wow great post... thanx...

  #20's very helpful!!!!

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