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Crush Step 3 CCS: The Ultimate USMLE Step 3 CCS Review This page intentionally left blank Crush Step 3 CCS: The Ultimate USMLE Step 3 CCS Review MAYUR K. MOVALIA, MD Internship, Internal Medicine University of Hawaii Honolulu, Hawaii Hematopathologist Dahl-Chase Pathology Associates Medical Director, Flow Cytometry Laboratory Dahl-Chase Diagnostic Services Medical Director, Affiliated Laboratories Eastern Maine Medical Center Bangor, Maine Medical Director, Cancer Care of Maine Laboratory Brewer, Maine Medical Director, Mount Desert Island Hospital Laboratory Bar Harbor, Maine Faculty and Instructor University of Maine Orono, Maine 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 CRUSH STEP 3 CCS: THE ULTIMATE USMLE STEP 3 CCS REVIEW ISBN: 978-1-4557-2374-4 Copyright © 2013 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Pub- lisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evalu- ating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instruc- tions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Movalia, Mayur. Crush step 3 CCS: the ultimate USMLE step 3 CCS review / Mayur K. Movalia. -- 1st ed. p. ; cm. ISBN 978-1-4557-2374-4 (pbk.) I. Title. [DNLM: 1. Clinical Medicine--Examination Questions. WB 18.2] 616.0076--dc23 2012036370 Senior Content Strategist: James Merritt Content Developmental Specialist: Christine Abshire Publishing Services Manager: Hemamalini Rajendrababu Project Manager: Kamatchi Madhavan Designer: Louis Forgione Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To my wonderful wife, Neela, and to my kids, Raina, Ryan, and Renee, for their laughter, encouragement, and unconditional support. Mayur K. Movalia This page intentionally left blank P H Y S I C I A N R E V I E W B O A R D Each of the following reviewers scored above the 90th percentile on USMLE Step 3 with most scoring in the 99th percentile. The author and publisher express sincere gratitude to these physicians for their many helpful comments, suggestions, and recommendations for improving the text that appears in this book. Whitney K. Bryant, MD, MPH Simulation and Medical Education Fellow Assistant Professor of Emergency Medicine University of Cincinnati Cincinnati, Ohio Yewlin E. Chee, MD Resident in Ophthalmology Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts Linda Hall, MD Family Physician Beartooth Billings Clinic Red Lodge, Montana Capt. Jason M. Johnson, MD, USAFR Clinical Fellow in Neuroradiology Massachusetts General Hospital Harvard Medical School Boston, Massachusetts Jessica J. Kraeft, MD Radiology Resident Mount Auburn Hospital Harvard Medical School Cambridge, Massachusetts Joseph T. Nezgoda, MD, MBA Ophthalmology Resident University Hospitals Case Medical Center Cleveland, Ohio vii This page intentionally left blank P R E F A C E The Computer-based Case Simulation (CCS) portion of USMLE Step 3 comprises 12 inter- active cases over 4 hours designed to evaluate your approach to patient management. This book was created to provide a high-yield, rapid, comprehensive review for the CCS cases. Studying for the CCS portion of Step 3 presents some unique challenges from studying for the multiple-choice question (MCQ) portion. Most important, understanding the USMLE CCS Primum® software is essential to performing well. As soon as you decide to take Step 3, download the Primum® CCS software from the official www.usmle.org website under “Practice Materials.” An in-depth review of the software is provided in this book. Practice the six cases that are supplied by the USMLE and get a good feel for how to place orders, what orders are available, how to manage the clock, how to transfer patients, and all the various features of the software. Practice the sample cases multiple times and see how the software responds to performing correct actions and performing incorrect actions. Once you are comfortable with the software, you can really start using this book and studying for the exam. This book incorporates the concept of bidirectional learning, which emphasizes relationship building and associative memories. Each CCS case is presented on two pages. The first page shows a brief sample case presentation with relevant information presented in a format similar to the actual exam. The second page presents a review of the disease entity with a focus on diagnosis, management, and important points in the CCS matrix. Each case can be studied beginning from the first page or the second page. How to Use This Book: n Asaself-test n To use as a self-test, begin with the first page of a case and read through the case presentation. In most cases, the diagnosis should be suspected from the information provided. On a blank sheet of paper or in your head, create a sequence for how you would manage the patient. Compare your management with what is presented on the second page. n Asareviewbook n To use as a review book, start backward with the second page of a case. At the top, the final diagnosis is listed. Beginning with the final diagnosis, try to recall important points in the diagnosis and management. In addition, create a CCS matrix with the six domains and compare your results with those listed in the table provided. n Asapracticeexam n To use as a practice exam, open a CCS case in the USMLE Primum® software (Case 1 begins in the emergency department and Case 2 begins in the office). Begin with the first page of a case and read through the introduction. Using the software, order the appropriate management (exam, labs, imaging, and treatment). Compare what you did in the software with the management recommended on the second page. Preparing well for the CCS portion of Step 3 can have a dramatic impact on your overall Step 3 score. If you learn the concepts, strategies, and cases in this book, you should not just do well on the CCS cases, you should CRUSH them! I wish you much success on your exam, residency, career, and future. Mayur K. Movalia, MD ix