The document discusses new changes to the USMLE Step 3 Clinical Case Simulations (CCS) component starting in February 2012, including fewer cases with longer times and more cases with shorter times. It provides tips on prioritizing tasks, sequencing orders, and monitoring patients in CCS cases. Key areas that are scored include diagnosis, location, timing, sequencing, and monitoring of patients. Guidance is given on stabilizing patients in emergency settings and managing conditions like shock, respiratory failure, and sepsis.

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20. Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case “ Presumed” or “Known” site of infection Possible “Bugs” Emperical therapy Community acquired pneumonia S.pneumoniae, Legionella, mycoplasma, H.influenzae Third generation cephalosporin + macrolide or Newer Quinolone Early Hospital Acquired Pneumonia ( < 5 days) Gram negative rods – non resistant ( e.coli, proteus, klebsiella), S.pneumonia, H.influenzae, legionella PIP/TAZO, Unasyn, Cefepime or newer quinolone Late Hospital Acquired Pneumonia ( > 5days) Resistant gram –ves (ESBL), Pseudomonas, MRSA Use anti-pseudomonal drugs – PIP/TAZO + quinolone, Cefepime, Imipenem, Vancomycin (if MRSA suspected) Intra abdominal infections ( diverticulitis) Enteric gram –ve rods ( E.coli), Anerobes (B.fragilis) Use good anerobic coverage : Cipro+flagyl, Pip/tazo, Ertapenem, Imipenem. Do not use cephalosporin alone ( add metronidazole if using it) Urinary tract infections E.coli, proteus Enterococci Quinolone, ceftriaxone, extended spectrum beta lactums, if enterococci is present  use ampicillin or vancomycin Meningitis S.pneumonia, H.influenzae, N.meningitidis, E.coli. In ages < 1month or > 50 years -Listeria Vanco+Ceftriaxone. If listeria suspected, add Ampicillin. Give Dexametasone prior to antibiotics Pseudomembranous colitis/ C.Difficle Diarrhea c.difficle Metronidazole p.o. If resistant, use vanco p.o ( do not use I.V vanco – not effective)

21. ER Setting – A simple approach Presenting Issue Next Step on CCS Vitals” are very unstable + you, absolutely, have no clue about the diagnosis from the history Go to “physical screen “ – do a very focused physical ( 2 minutes – Chest and Cardiovascular. Consider “abdomen” only if history revealed abdominal pain or trauma)  Proceed to order sheet (Remember that when you have no clue from the history, a “Life” saving step for a severely unstable vital may not be identified until you do the “2-Minute” ( Chest, Cardiovascular) physical). Remember that if this step is done early ( less “Simulated” time), you will get maximum score “ Vitals” are “UNSTABLE” ( Shock or respiratory failure) + you have a clue about the diagnosis from the history Proceed to “Order sheet” and try to stabilize. Write “Stabilizing” orders, “Basic” orders, “Symptom” relieving orders. Write “Specific” diagnostic tests and “Specific” treatment since you already have a clue about the diagnosis from the history ( Some examples: Anaphylactic shock, Hypovolemic shock from MVA , strong clues of “PE” in the history ) “ Vitals” are “Stable” no “ Pain” Full physical and then go to “order” sheet “ “ Vitals” stable but History reveals severe “pain” Address pain first and then come back to physical screen ( except in abdominal pain – do abdomen exam first and then address pain)

56. Shock

57. Respiratory Failure