Exam Prep
Step 3 CCS Comprehensive Guide (Made Easy)
Apr 10, 20268 min read
By Mike
By MikeBy MikeUWorld is more than enough for Step 3. Aim to complete as much of the question bank as possible, though even 60–70% with thorough review of incorrects will cover what you need. Start taking preparation seriously about 3 weeks before your exam. UWorld questions are very similar to the real exam in both style and difficulty.
Supplement with the Dorian Step 3 Anki deck in the final week for a rapid-fire refresher. Read the First Aid biostats section and skim the rapid review in the back of the book. You do not need to purchase additional resources — UWorld, the Dorian deck, and First Aid biostats will cover the vast majority of tested content.
The single most important resource is the Official USMLE Step 3 Practice Questions. These are the most representative of the real exam in both multiple choice and CCS format, and likely use the most accurate grading rubric for CCS cases. Do these before anything else.
Step 3 is a two-day exam. Understanding the structure will help you allocate your study time.
Day 1 — The "Step 1 Day": 6 blocks of ~40 questions each (1 hour per block). Heavy on Step 1 factoids, biostats, ethics, and risk factor identification alongside diagnosis and treatment questions. This is widely considered the harder day because it tests knowledge you may not have revisited since Step 1. Reviewing biostats from First Aid and the rapid review video playlists will help considerably.
Day 2 — The "Clinical Day": 6 blocks of 30 questions each (45 minutes per block), focused on diagnosis and management of medical conditions. These are more straightforward and clinically intuitive. Many test-takers complete blocks back-to-back without breaks. Day 2 also includes the CCS cases, which are either 10 or 20 minutes in length and account for 25% of your total grade.
CCS cases often differ from real clinical practice. What you would do on the wards is frequently not what the USMLE rewards. The key principles to internalize:
If you are pressed on time and fairly confident about passing, just do the official CCS cases and review their grading criteria.
The CCS grading criteria assess six domains. Use the following systematic approach for every case.
Keep the exam focused. You will have a good idea of your differential diagnosis after reading the case introduction and vitals. Select the relevant exam components from the following options:
Physical appearance, Skin, Breast, Lymph nodes, HEENT/Neck, Chest/Lungs, Heart/Cardio, Abdomen, Genitalia, Rectal, Extremities/Spine, Neuro/Psych
Order basic monitoring for every patient: cardiac monitor, pulse ox, accucheck.
Use this mnemonic at the start of every acute/emergent case to stabilize the patient.
Hurting (morphine) Access IV, IV fluids, Accucheck, ABG Vitals Oxygen, pulse ox, naloxone Cardiac — EKG, cardiac monitor, C-spine precautions
Cast a wide net. Cost does not matter on CCS. Order from each category as clinically relevant.
Imaging: CXR, CT Head, CT Chest, TTE Blood: CBC, BMP, TSH, ABG, B12, B9, thiamine, calcium, lipase/amylase, mag, A1c, lipids, LFTs Urine: UA, urine culture, urine ketones, urine protein, urine gram stain Other: Peak flow, FOBT, cardiac enzymes, rheumatologic labs Pregnancy: Serum pregnancy test Micro: Blood culture, urine antigen, urine culture Toxins: Urine tox screen, serum ethanol, serum acetaminophen
Once you have a working diagnosis and results are returning, initiate treatment and admission orders.
Activity, airway, antibiotics Blood (IV) — IV fluids CBC, BMP Diet (diabetic, low salt, NPO, regular, cardiac) Elevate head of bed (ICU or intubated) Foley, urine output Gastric — Zofran, NG tube, PPI Hurt — Tylenol Isolation
If a procedure or surgery is indicated, use this checklist before ordering.
NPO, NSS Informed consent Cefazolin EKG PT/PTT Type and screen Rh type (pregnant woman) Surgery name
Order consults whenever applicable, ideally after stabilization is complete and you have a definitive or working diagnosis.
High-yield consults to consider: Cardiology, Psychiatry, Social services, Surgery, Gastroenterology, Nutrition, Poison control.
After the patient improves and before ending the case, always address preventative care. This is commonly missed and is an easy source of points.
Pneumococcal Meningococcal Influenza Shingles Tdap
Pap smear Mammogram Colonoscopy Counsel (medication side effects, diabetes, cancer diagnosis, etc.) Reassure!!! Exercise program, Diet Alcohol cessation Safe sex, Seatbelt Smoking cessation, Social work
Location: Emergency Department Chief Complaint: Chest pain Case: A 58-year-old man presents with a 30-minute history of crushing chest pain radiating to the left arm, associated with shortness of breath, diaphoresis, and nausea. PMH includes possible hypertension and hyperlipidemia. Family history of cardiac disease. Pain is 8/10, not pleuritic, not relieved by Tylenol or ibuprofen.
1. Focused Physical Exam: Physical appearance, Chest/Lungs, Heart/Cardio, Abdomen, Extremities/Spine
2. Stabilizing Orders (HAVOC): Morphine for pain, IV access + IV fluids + accucheck + ABG, vitals, oxygen + pulse ox, EKG + cardiac monitor
3. Diagnostic Orders (I BUOP Micro Toxins): CXR and TTE for imaging. CBC, BMP, cardiac enzymes (troponin), lipids, A1c, LFTs for blood. UA for urine. Serum pregnancy test if applicable.
4. Treatment/Admit Orders (ABCs-DEFGHI): Aspirin, clopidogrel/ticagrelor, heparin, beta-blocker, statin, nitroglycerin. Cardiac diet. Admit to ICU/CCU with continuous monitoring.
5. Procedure Orders (NICE PTS): If cardiac catheterization is indicated — NPO, informed consent, cefazolin, EKG, PT/PTT, type and screen, order cardiac catheterization.
6. Consults: Cardiology consult.
7. Preventative Care (after patient improves): Vaccines (P-MIST as age-appropriate), screening (PMCs-CREASS), counsel on smoking cessation, exercise, diet, medication adherence, cardiac rehabilitation referral.
Short answer: Not really. A passing score is 200, and most residency programs and fellowships weigh Step 2 CK, research, and recommendations far more heavily. Some competitive IM subspecialty fellowships may glance at Step 3, but it is rarely a deciding factor. Use your scores on Step 1 and Step 2 to gauge how much additional studying you need. Intern year is demanding — prioritize recovery, family, and self-care over over-studying for this exam.
Best of luck!
— Mike