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13 High-Yield CCS Cases for USMLE Step 3 - Detailed Walkthrough

How CCS Scoring Works (Read This First)

Each CCS case is worth ~3% of your total Step 3 score (9 cases on exam day). The software rewards:

Timely stabilization - act on danger signs immediately
Correct care setting - wrong venue costs hidden points
Focused, not shotgun, diagnostics - every test should change management
Time advancement - you must actively advance the clock to get results and observe response
Monitoring, counseling, and follow-up - these earn background points at the end

The universal opening sequence for any unstable patient:

IV access + O2 + monitors (ECG, pulse ox, BP cuff) + focused history/exam -> initial orders -> advance clock -> reassess -> adjust -> disposition

Case 1: STEMI (Acute MI)

Presentation: 55-year-old male with crushing substernal chest pain radiating to the left arm for 45 minutes. Diaphoresis. BP 140/90, HR 100, O2 sat 96%.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate stabilization orders (all at once):
- Continuous ECG monitoring, pulse ox, BP monitoring
- IV access x2
- O2 via nasal cannula (only if sat <94%)
- 12-lead ECG - do this first, do not delay
- Aspirin 325 mg PO (chew)
- Sublingual nitroglycerin (if no RV infarct, no hypotension)
- Morphine 2-4 mg IV (for pain, use judiciously)
- Troponin, BMP, CBC, PT/INR, type & screen
- CXR portable
ECG shows ST elevation in leads II, III, aVF (inferior STEMI):
- Right-sided leads (V4R) to rule out RV infarction - if present, avoid nitrates
- Heparin IV bolus + infusion (or enoxaparin)
- Clopidogrel (P2Y12 inhibitor) loading dose
- Call cardiology / activate cath lab
Definitive management:
- Primary PCI is goal within 90 minutes of first medical contact - this is the answer on CCS
- If PCI not available within 120 min: thrombolysis with tPA (if no contraindications)
- Transfer to ICU/CCU after stabilization
Advance time, check results:
- Troponin elevated: confirms MI
- Monitor for Mobitz II / complete heart block (inferior STEMI complication)
- Temporary pacemaker orders ready
Discharge counseling (before case ends):
- Beta-blocker, statin, ACE inhibitor, dual antiplatelet therapy
- Cardiac rehab referral, dietary counseling, smoking cessation

Key CCS pitfall: Never delay aspirin waiting for troponin results. Never give nitrates with RV infarct (BP will crash).

Case 2: Sepsis / Septic Shock

Presentation: 68-year-old female nursing home resident, fever 39.8°C, HR 118, BP 88/54, RR 24, confused. Dysuria for 3 days.

Setting: Emergency Department -> ICU

Step-by-step CCS approach:

First screen - all simultaneous:
- IV access x2 (large bore)
- O2 (high-flow if sat low)
- Continuous monitoring
- Blood cultures x2 sets (before antibiotics - this earns a major point)
- Urinalysis + urine culture + urine Gram stain
- CBC, BMP, lactate, LFTs, coagulation panel, blood gas
- CXR
Start antibiotics within 1 hour (do not wait for culture results):
- Broad-spectrum: Piperacillin-tazobactam or Cefepime + Vancomycin
- If penicillin allergic: Aztreonam + Vancomycin
Fluid resuscitation:
- 30 mL/kg IV crystalloid bolus (normal saline or lactated Ringer's)
- Reassess BP and lactate after
Advance time 30-60 minutes:
- If BP still <65 mmHg MAP despite fluids: Norepinephrine (vasopressor of choice)
- If adrenal insufficiency suspected: Hydrocortisone 200 mg/day IV
Transfer to ICU
Narrow antibiotics when cultures result (usually Gram-negative rods from urine -> switch to ceftriaxone or fluoroquinolone if sensitive)
Before case ends:
- Foley catheter for urine output monitoring
- DVT prophylaxis
- Stress ulcer prophylaxis
- Glycemic control (keep glucose <180)

Key CCS pitfall: Blood cultures BEFORE antibiotics. Lactate >4 = severe sepsis/septic shock regardless of BP. Norepinephrine is first-line vasopressor (not dopamine).

Case 3: Acute Ischemic Stroke

Presentation: 72-year-old male with sudden onset right-sided weakness, facial droop, slurred speech. Last known well: 2.5 hours ago. BP 185/100, NIHSS 14.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate orders:
- ABCs, IV access, O2 (only if sat <94%)
- Continuous monitoring
- Non-contrast CT head STAT (must rule out hemorrhage before tPA)
- Blood glucose STAT (hypoglycemia mimics stroke)
- CBC, BMP, PT/INR, PTT, type & screen
- 12-lead ECG (look for Afib as source)
CT head = no hemorrhage, glucose normal:
- tPA (alteplase) IV within 4.5 hours of symptom onset is the answer
- tPA dose: 0.9 mg/kg (max 90 mg) - 10% bolus, rest over 60 min
- Blood pressure must be <185/110 before tPA - use labetalol or nicardipine to lower if needed
Contraindications to tPA (know these cold):
- Hemorrhage on CT
- BP >185/110 uncontrolled
- Anticoagulant use (recent)
- Recent surgery within 14 days
- Stroke/head trauma within 3 months
- Platelet <100,000, glucose <50
Advance time:
- Monitor BP every 15 min during/after tPA
- Neuro checks frequently
- If large vessel occlusion (MCA): Mechanical thrombectomy within 24 hours of last known well (neurology/interventional radiology consult)
Admit to stroke unit / ICU:
- No heparin/anticoagulation for 24 hours after tPA
- NPO initially (aspiration risk) - get speech therapy/swallowing eval
- Start aspirin 24 hours post-tPA
- MRI brain, MRA (carotid ultrasound, echocardiogram for source)
Discharge:
- Aspirin + statin
- Antihypertensive
- If Afib found: anticoagulate (DOACs preferred)
- PT, OT, speech therapy referrals

Key CCS pitfall: Do not lower BP aggressively in ischemic stroke (penumbra needs perfusion) unless tPA is being given. Do NOT give tPA if stroke symptoms are rapidly improving (likely TIA).

Case 4: Hypertensive Emergency / Encephalopathy

Presentation: 48-year-old male with severe headache, confusion, blurred vision. BP 240/130. No focal neurologic deficits. No history of stroke.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate orders:
- IV access, monitoring
- Non-contrast CT head (rule out hemorrhage/stroke first)
- BMP (renal function - assess end-organ damage)
- Cardiac enzymes (rule out ACS)
- Urinalysis (proteinuria/hematuria = renal injury)
- CXR (pulmonary edema, aortic widening)
- 12-lead ECG
- Fundoscopic exam (papilledema, flame hemorrhages)
CT shows no hemorrhage, no focal deficits = Hypertensive Encephalopathy:
- Nicardipine or Labetalol IV (titratable IV agents)
- Nitroprusside IV drip is acceptable if SBP >220
- Goal: Reduce MAP by 15-20% in first hour (NOT normalize BP - too fast = ischemia)
- Avoid: Hydralazine (unpredictable), nifedipine sublingual (reflex tachycardia)
Advance time, monitor BP every 15-30 minutes:
- Titrate drip to target MAP
- Watch for deterioration (new focal deficits = possible hemorrhagic conversion)
Once BP controlled, transition to oral agents:
- Lisinopril, amlodipine, metoprolol
- Taper IV drip as oral agents take effect
Admit to ICU/step-down:
- 24-hour monitoring
- Nephrology consult if creatinine elevated

Key CCS pitfall: Hypertensive urgency (no end-organ damage) can be managed with oral meds and outpatient follow-up. Hypertensive emergency REQUIRES IV agents. Lowering BP too fast causes watershed infarcts.

Case 5: Pulmonary Embolism

Presentation: 55-year-old woman, 3 days post-op right hip replacement, sudden onset dyspnea, pleuritic chest pain, HR 118, O2 sat 90%, BP 100/70.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate orders:
- IV access, O2 (high-flow), continuous monitoring
- 12-lead ECG (look for S1Q3T3, sinus tachycardia, new RBBB)
- ABG
- D-dimer (high pre-test probability here - will be elevated but NOT used to rule out)
- BMP, CBC, troponin, BNP
- CXR (Hampton's hump, Westermark sign - usually normal)
- Lower extremity Doppler
Definitive diagnosis: CT Pulmonary Angiography (CTPA):
- High pre-test probability + hemodynamic instability = start treatment immediately
- CTPA confirms massive/submassive PE
Treatment:
- Hemodynamically stable (submassive): Anticoagulation - Heparin IV or enoxaparin SC, then transition to DOAC (rivaroxaban, apixaban) or warfarin
- Massive PE (BP <90 despite fluids, or cardiac arrest): Systemic thrombolysis (tPA 100 mg IV over 2 hours) or surgical embolectomy
- Avoid excessive IV fluids (worsens RV dilation)
Admit to floor vs ICU:
- Massive PE: ICU
- Submassive (RV strain on echo/troponin): step-down or ICU
Long-term:
- DOAC for 3-6 months (provoked PE - post-op context)
- IVC filter only if anticoagulation contraindicated
- Compression stockings

Key CCS pitfall: Wells criteria determines pre-test probability. Low probability + negative D-dimer = no CTPA needed (rule out). Do not wait for CTPA to start heparin in unstable patients.

Case 6: Community-Acquired Pneumonia (CAP)

Presentation: 67-year-old male, 3-day history of fever, productive cough with rust-colored sputum, RR 22, O2 sat 93%, BP 118/78, HR 98. Dullness to percussion at the right base.

Setting: ED/Floor

Step-by-step CCS approach:

Orders:
- O2, monitoring
- CXR (right lower lobe infiltrate expected)
- Sputum Gram stain and culture (before antibiotics)
- Blood cultures x2 (hospitalized patients - especially if immunocompromised)
- CBC, BMP, procalcitonin
- Pulse oximetry continuous
- Urinary pneumococcal antigen + Legionella antigen
Calculate PSI/PORT score or CURB-65 to determine admission vs outpatient:
- CURB-65: Confusion, Urea >7, RR >30, BP <90/60, Age >65 - score 2+ = admit
- This patient: Age 67, RR 22, O2 sat 93% -> admit to floor
Antibiotic selection (inpatient, non-ICU):
- Beta-lactam (ceftriaxone 1g IV daily) + Azithromycin (500 mg IV/PO)
- OR respiratory fluoroquinolone monotherapy (levofloxacin 750 mg)
Advance time 24-48 hours:
- Reassess fever, O2 requirement, respiratory status
- Switch to oral antibiotics when tolerating PO and improving
Total antibiotic duration: 5 days (if responding well)
Discharge criteria:
- Afebrile x2, HR <100, RR <24, O2 sat >90% on room air, tolerating oral intake
Counseling:
- Pneumococcal vaccine (Prevnar 20 or PCV15+PPSV23) at discharge
- Influenza vaccine (seasonal)
- Smoking cessation

Key CCS pitfall: ICU-level CAP needs dual coverage (beta-lactam + azithromycin OR fluoroquinolone + beta-lactam). Atypical coverage (Legionella, Mycoplasma) is important in hospitalized patients.

Case 7: Acute Asthma Exacerbation

Presentation: 22-year-old woman, severe dyspnea, wheezing, uses albuterol inhaler at home without relief. HR 118, RR 28, O2 sat 91%, speaking in partial sentences.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate orders:
- O2, continuous pulse ox and monitoring
- Albuterol (salbutamol) nebulizer STAT - continuous vs every 20 min x3 doses
- Ipratropium bromide nebulizer (add to first 3 doses)
- IV methylprednisolone 125 mg (or prednisone PO if mild-moderate)
- ABG if O2 sat not improving
- CXR (rule out pneumothorax, pneumonia trigger)
- Peak expiratory flow rate (PEFR)
Advance time 20-30 minutes:
- If improving (O2 sat >95%, speaking full sentences, PEFR >70% predicted): Observe, transition to MDI, may discharge
- If not improving: Magnesium sulfate 2g IV (bronchodilator for severe acute asthma)
- Heliox (helium-oxygen) mixture for severe refractory cases
Warning signs of impending respiratory failure (intubate):
- "Silent chest" (no wheeze = no air movement)
- Rising PaCO2 (normal or elevated = patient tiring out)
- Altered mental status
- If intubating: use ketamine for RSI (bronchodilator), set permissive hypercapnia on ventilator
Discharge criteria (if improving):
- O2 sat >92% on room air
- PEFR >70% predicted
- Able to tolerate PO
- Prescription: ICS + LABA controller inhaler, albuterol rescue
- Follow up with pulmonologist/PCP in 1-2 weeks
- Identify and avoid triggers
- Asthma action plan

Key CCS pitfall: Normal or rising CO2 in an asthmatic who looks tired is an emergency - they can no longer compensate. Do NOT sedate a non-intubated asthmatic.

Case 8: Diabetic Ketoacidosis (DKA)

Presentation: 24-year-old Type 1 diabetic, nausea/vomiting x2 days, "fruity breath," Kussmaul breathing. BS 480, pH 7.18, HCO3 10, anion gap 26, K+ 5.8.

Setting: Emergency Department -> ICU/Floor

Step-by-step CCS approach:

Immediate orders:
- IV access x2, continuous monitoring
- BMP, ABG, CBC, beta-hydroxybutyrate (or urine ketones)
- UA, urine culture (look for infection as precipitant)
- CXR, 12-lead ECG (hyperkalemia effects)
- Blood cultures if sepsis suspected
Fluids FIRST (before insulin):
- Normal saline (0.9% NaCl) 1-2L IV bolus over first hour
- Then 250-500 mL/hour until hemodynamically stable
Insulin drip (only after K+ >3.5 - critical!):
- Regular insulin IV 0.1 units/kg/hr
- If K+ <3.5: Give potassium first, hold insulin (hypokalemia from insulin can cause cardiac arrest)
- Switch to D5W + 0.45% NS when glucose <250 (to avoid hypoglycemia while continuing insulin for ketone clearance)
Potassium replacement:
- Add K+ to IV fluids to keep serum K+ 3.5-5.0 mEq/L throughout
- Initial high K+ will drop dramatically once insulin is started
Monitor every 1-2 hours:
- BMP (glucose, K+, HCO3)
- Repeat ABG
- Anion gap resolution is the marker of DKA resolution (NOT glucose normalization)
Transition to subcutaneous insulin when:
- pH >7.3, HCO3 >15, AG normal, able to eat
- Overlap IV and SC insulin by 2 hours
Identify and treat precipitant:
- Infection: start antibiotics
- Missed insulin: patient education
- New diagnosis: diabetes education

Key CCS pitfall: Do NOT start insulin without checking K+. DKA is not resolved when glucose normalizes - wait for anion gap closure. Do NOT use bicarb (except pH <6.9 with hemodynamic compromise).

Case 9: Meningitis

Presentation: 20-year-old college student, severe headache, fever 39.5°C, neck stiffness, photophobia. HR 112, BP 110/70. Petechial rash on trunk and extremities.

Setting: Emergency Department

Step-by-step CCS approach:

This is a medical emergency - speed matters:
- IV access, monitoring, O2
- Blood cultures x2 IMMEDIATELY
- CBC, BMP, coagulation panel (DIC from meningococcemia?)
- Start empirical antibiotics immediately - do NOT wait for LP
Empirical antibiotics (adult 18-50):
- Ceftriaxone 2g IV q12h (covers N. meningitidis, S. pneumoniae)
- Vancomycin 15-20 mg/kg IV q8-12h (for resistant S. pneumoniae)
- Dexamethasone 0.15 mg/kg IV q6h x4 days (start before or with first antibiotic dose - reduces neurologic complications)
- For age >50 or immunocompromised: Add Ampicillin (covers Listeria)
LP (lumbar puncture) after antibiotics if:
- No papilledema, no focal neurologic deficit, not coagulopathic
- CT head first if any risk factors for herniation
CSF results:
- Bacterial: cloudy, high WBC (PMNs), low glucose, high protein
- Viral: clear, lymphocytes predominant, normal glucose, mildly elevated protein
Advance time, reassess:
- If improving on antibiotics: narrow based on CSF cultures
- Contact precautions for meningococcal meningitis
- Prophylaxis for close contacts: Rifampin or Ciprofloxacin
Admit to ICU (this patient has petechial rash = meningococcemia - high risk of septic shock, DIC, Waterhouse-Friderichsen syndrome)
Complications to watch:
- SIADH (restrict free water)
- Seizures (levetiracetam or phenytoin)
- Hydrocephalus

Key CCS pitfall: Antibiotics BEFORE LP if LP will be delayed. Corticosteroids earn points only if given with first antibiotic dose.

Case 10: Acute Appendicitis

Presentation: 25-year-old male, 18 hours of periumbilical pain migrating to RLQ, nausea, low-grade fever 38.2°C. Rebound tenderness at McBurney's point. WBC 14,500.

Setting: Emergency Department

Step-by-step CCS approach:

Initial orders:
- IV access, monitoring
- NPO immediately
- IV fluids (maintenance)
- CBC, BMP, LFTs, amylase/lipase
- UA (rule out renal colic, UTI)
- Beta-hCG (female patients - always rule out ectopic pregnancy first)
- Morphine/ketorolac for pain (do NOT withhold analgesics - old teaching was wrong)
Imaging:
- CT abdomen/pelvis with contrast is the gold standard
- Ultrasound first in pregnant women or children (radiation avoidance)
- Alvarado score can supplement
CT confirms acute appendicitis:
- Surgery consult
- Metronidazole + Cefoxitin IV (or ceftriaxone + metronidazole) - pre-op antibiotics
- Consent, anesthesia consult
- Laparoscopic appendectomy
Perforation/abscess found:
- Broad-spectrum antibiotics (piperacillin-tazobactam)
- May need IR-guided drainage first, then interval appendectomy in 6-8 weeks
Post-op:
- Advance diet when bowel function returns
- Discharge when tolerating PO, afebrile, pain controlled on oral meds
- Wound care instructions, return precautions

Key CCS pitfall: Beta-hCG before surgery in any woman of reproductive age. Do not delay surgery consultation waiting for additional imaging. Analgesics are appropriate and encouraged.

Case 11: Pre-eclampsia / Eclampsia

Presentation: 28-year-old G1P0 at 36 weeks gestation, BP 162/108, headache, visual changes, 3+ proteinuria on dipstick. Reflexes 3+ brisk.

Setting: Labor and Delivery / ICU

Step-by-step CCS approach:

Immediate orders:
- IV access, continuous fetal monitoring (cardiotocography)
- Magnesium sulfate IV: 4-6g loading dose over 20 min, then 1-2g/hour maintenance (seizure prophylaxis AND treatment)
- Labs: CBC, BMP, LFTs, uric acid, 24-hour urine protein (or spot protein:creatinine ratio), coagulation panel (rule out HELLP)
- Fetal biophysical profile / non-stress test
- Urine output monitoring (Foley catheter)
Control BP:
- Acute: Labetalol IV 20mg (repeat q10 min, max 300mg) OR Hydralazine 5-10mg IV OR Nifedipine 10mg PO
- Target: SBP 140-155, DBP 90-105 (avoid over-correction - placental perfusion)
Definitive treatment = DELIVERY:
- Severe features (BP >160/110, headache, visual changes, thrombocytopenia, elevated LFTs): deliver at 34+ weeks
- This patient at 36 weeks: Deliver
- Vaginal delivery preferred if cervix favorable; C-section for obstetric indications
If seizure occurs (eclampsia):
- Magnesium sulfate is treatment AND prophylaxis (not diazepam or phenytoin)
- If breakthrough seizure on Mg: additional 2g IV bolus
- Check Mg levels (therapeutic: 4-7 mEq/L; toxic: >7)
- Calcium gluconate at bedside (reverses Mg toxicity)
HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets):
- Also warrants delivery
- Corticosteroids can be given for fetal lung maturity if <34 weeks
- Platelet transfusion if <50,000 and C-section planned
Post-partum monitoring:
- Continue Mg for 24-48 hours post-delivery
- BP monitoring for 72 hours (BP can worsen post-partum)

Key CCS pitfall: Magnesium for seizure prophylaxis, NOT a BP-lowering drug. Delivery is the only cure. Do NOT use ACE inhibitors or ARBs in pregnancy.

Case 12: Major Depressive Episode / Suicidal Patient

Presentation: 35-year-old female brought in by husband after he found a suicide note. She took "a handful of pills" 2 hours ago. Lethargic, HR 118, pupils dilated, dry skin, confusion.

Setting: Emergency Department

Step-by-step CCS approach:

Toxicology emergency first (TCA overdose signs - anticholinergic + cardiac toxicity):
- IV access, continuous cardiac monitoring, O2
- ECG immediately (wide QRS >100ms = TCA toxicity - risk of ventricular arrhythmia)
- Fingerstick glucose
- Tylenol and salicylate levels (always check with unknown overdose)
- BMP, CBC, LFTs, ABG
- Serum drug screen, urine toxicology
- Activated charcoal 1g/kg PO if <1-2 hours since ingestion and airway protected
TCA overdose management:
- QRS >100ms or ventricular arrhythmia: Sodium bicarbonate IV (1-2 mEq/kg bolus, then drip to maintain pH 7.45-7.55)
- Avoid physostigmine (increases seizure risk)
- Benzodiazepines for seizures (NOT phenytoin)
- Avoid flumazenil if benzodiazepines co-ingested (precipitates seizures)
Once medically stable:
- Psychiatric consult
- Suicide risk assessment (Columbia Suicide Severity Rating Scale)
- Involuntary hold / Baker Act if patient refuses and remains at risk
For underlying MDD (once medically clear):
- SSRI (first-line): sertraline, escitalopram
- SNRIs: venlafaxine, duloxetine
- Avoid TCAs in suicidal patients (lethal in overdose - this is why she's here)
- Mirtazapine: good for insomnia + depression
Discharge/Disposition:
- Inpatient psychiatric admission for suicidal ideation with plan and intent
- Remove means from home (lethal means counseling)
- Safety plan
- Follow-up with outpatient psychiatry in 1 week

Key CCS pitfall: ECG is the most important early test for unknown overdose. Sodium bicarb is the antidote for TCA cardiac toxicity. Never discharge a suicidal patient without adequate psychiatric evaluation.

Case 13: Pediatric Febrile Seizure vs. Meningitis

Presentation: 18-month-old boy, first-time seizure lasting 2 minutes, generalized tonic-clonic, stopped spontaneously. Fever 39.5°C since yesterday. Now post-ictal but arousable. No stiff neck, no rash. Immunizations up to date.

Setting: Emergency Department

Step-by-step CCS approach:

Immediate assessment:
- ABCs, O2 via mask
- Fingerstick glucose
- IV/IO access
- Continuous monitoring
- Full physical exam (look for meningismus, Kernig/Brudzinski signs, rash)
- Ear exam (otitis media as fever source), throat exam, skin
This is a simple febrile seizure if:
- Age 6 months - 5 years
- Duration <15 minutes
- Generalized (not focal)
- Single episode in 24 hours
- Returns to normal baseline
- No signs of meningitis/encephalitis
Workup for simple febrile seizure:
- Identify and treat the fever source (UA, CXR if respiratory symptoms)
- CBC, BMP, blood culture if toxic-appearing
- LP is NOT routinely required for simple febrile seizure in immunized child
- EEG is NOT required acutely for first simple febrile seizure
Management:
- Antipyretics: ibuprofen or acetaminophen (for comfort, does NOT prevent recurrence)
- Treat underlying infection (if otitis media: amoxicillin; if viral: supportive)
- Observe in ED 4-6 hours
Parent counseling (critical for CCS points):
- Risk of recurrence is 30-50%
- Does NOT cause brain damage or epilepsy (simple febrile seizures)
- If seizure >5 minutes: Rectal diazepam (Diastat) for home use
- Return precautions: prolonged seizure, focal features, not returning to baseline
Complex febrile seizure (focal, >15 min, multiple in 24h) = admit and consider LP/EEG
Meningitis signs present = treat as meningitis (see Case 9):
- LP
- Empirical ceftriaxone + vancomycin + dexamethasone

Key CCS pitfall: Do NOT reflexively do LP on every febrile child with seizure if immunized and exam is normal. Do NOT use prophylactic anticonvulsants. Rectal diazepam is appropriate for home use only.

Universal CCS Strategies - Quick Reference

Phase	What to Do
First screen	Safety bundle: IV, O2, monitors, focused exam, key labs
Setting	Choose correct venue before advancing time
Diagnostics	Focused tests that CHANGE management only
Treatment	Empirical therapy while awaiting results
Advance clock	Short hops (15-30 min to hours) to observe response
Reassess	Adjust or narrow therapy based on results
Disposition	Admit/transfer/discharge with documented criteria
End of case	Counseling, follow-up, preventive care orders

The top pitfalls that cost points:

Ordering antibiotics before blood/CSF cultures
Giving insulin without checking potassium (DKA)
Giving nitrates with RV infarct
Lowering BP too fast in ischemic stroke
Not giving tPA within window for ischemic stroke
Not delivering in severe pre-eclampsia
Not checking beta-hCG before surgery in women of reproductive age
Discharging a suicidal patient without psychiatric evaluation
Doing LP before CT when herniation is a risk
Not advancing the clock (sitting on orders without moving time forward)

Make a presentation on high-yield medications and dosing for Step 3 CCS

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      options: { breakLine: i < bodyLines.length - 1, fontSize: 9, color: C.offWhite, fontFace: "Calibri" }
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      x: x + 0.12, y: y + 0.42, w: w - 0.24, h: h - 0.52,
      valign: "top", margin: 0
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}

function addTableSlide(slide, headers, rows, x, y, w, colW) {
  const tableRows = [];
  // header row
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    text: h,
    options: { fill: { color: C.teal }, color: C.white, bold: true, fontSize: 9.5, fontFace: "Calibri", align: "center" }
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  rows.forEach((row, ri) => {
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      text: cell,
      options: {
        fill: { color: ri % 2 === 0 ? C.card : "132840" },
        color: ci === 0 ? C.amber : C.offWhite,
        bold: ci === 0,
        fontSize: 9,
        fontFace: "Calibri",
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      }
    })));
  });
  slide.addTable(tableRows, { x, y, w, colW, border: { pt: 0.5, color: "1A3A5C" } });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – COVER
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };

  // Large teal bar left
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 0.18, h: 7.5, fill: { color: C.teal }, line: { color: C.teal }
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  // Bottom accent
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 6.6, w: 13.3, h: 0.9, fill: { color: C.card }, line: { color: C.card }
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  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 6.58, w: 13.3, h: 0.05, fill: { color: C.amber }, line: { color: C.amber }
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  s.addText("HIGH-YIELD MEDICATIONS", {
    x: 0.4, y: 1.1, w: 12.5, h: 0.9,
    fontSize: 44, bold: true, color: C.white, fontFace: "Calibri",
    charSpacing: 3, align: "left"
  });
  s.addText("& DOSING FOR USMLE STEP 3 CCS", {
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    fontSize: 28, bold: false, color: C.tealLt, fontFace: "Calibri",
    charSpacing: 1, align: "left"
  });
  s.addText("Master the orders that earn the most CCS points", {
    x: 0.4, y: 2.75, w: 12.5, h: 0.4,
    fontSize: 15, color: C.amber, fontFace: "Calibri", italic: true
  });

  // Decorative circles
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  // Categories preview
  const cats = ["Cardiac", "Neurology", "Pulm/ID", "Endo", "OB/GYN", "Psych", "GI/Surg"];
  cats.forEach((c, i) => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, {
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      fontSize: 9.5, color: C.white, bold: true, fontFace: "Calibri",
      align: "center", valign: "middle", margin: 0
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  });

  s.addText("USMLE Step 3 CCS Review  •  Clinical Pharmacology", {
    x: 0.4, y: 6.65, w: 12.5, h: 0.35,
    fontSize: 10, color: C.slateL, fontFace: "Calibri"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – CCS SCORING STRATEGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "CCS SCORING STRATEGY", "Why medications matter — and how they're scored");

  const tips = [
    ["Order EARLY", "Medications given promptly earn more points.\nDo not wait for all labs before empirical therapy."],
    ["Right Drug + Dose", "Wrong dose = partial credit.\nKnow IV vs PO, loading vs maintenance."],
    ["Monitor & Adjust", "Check drug response, levels, and side effects.\nAdvance time to observe results."],
    ["Narrow/Stop", "De-escalate antibiotics when cultures return.\nDiscontinue drugs no longer needed."],
    ["Counseling", "Before discharge: name the drug, explain purpose,\nside effects, and follow-up plan."],
  ];

  tips.forEach(([title, body], i) => {
    const x = 0.25 + (i % 3) * 4.35;
    const y = i < 3 ? 1.25 : 3.5;
    const w = 4.1;
    const h = 1.85;

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      fill: { color: C.card }, line: { color: C.teal, pt: 1.5 }, rectRadius: 0.1
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      fill: { color: C.amber }, line: { color: C.amber }
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    s.addText(`${i + 1}. ${title}`, {
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      fontSize: 11, bold: true, color: C.amber, fontFace: "Calibri", margin: 0
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    s.addText(body, {
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      fontSize: 10, color: C.offWhite, fontFace: "Calibri", margin: 0
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  // Bottom note
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    x: 0.25, y: 6.45, w: 12.8, h: 0.65,
    fill: { color: "0A1628" }, line: { color: C.teal, pt: 1 }
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  s.addText("KEY PRINCIPLE:  Order meds + advance the clock. The software CANNOT credit orders you never placed.", {
    x: 0.4, y: 6.48, w: 12.5, h: 0.55,
    fontSize: 11, color: C.amber, bold: true, fontFace: "Calibri", margin: 0, valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – CARDIAC: ACS / STEMI
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "CARDIAC — ACS / STEMI", "Meds to order in the first 5 minutes");

  const headers = ["Medication", "Route / Dose", "Timing", "Key Point"];
  const rows = [
    ["Aspirin", "325 mg PO (chew)", "Immediately", "Do NOT wait for troponin — order on first screen"],
    ["Nitroglycerin", "0.4 mg SL q5 min x3", "Immediately", "HOLD if SBP <90 or suspected RV infarct"],
    ["Morphine", "2–4 mg IV q5–10 min", "For refractory pain", "Caution in NSTEMI (may worsen outcomes)"],
    ["Heparin (UFH)", "60 U/kg IV bolus, then 12 U/kg/hr", "After ECG confirms ACS", "Adjust per aPTT (goal 60–80 sec)"],
    ["Clopidogrel", "600 mg PO loading dose", "Before PCI", "P2Y12 inhibitor; hold if CABG possible"],
    ["Ticagrelor", "180 mg PO loading dose", "Alternative to clop.", "Preferred in ACS — faster onset"],
    ["Metoprolol", "25–50 mg PO q6h", "Stable, no HF/shock", "Hold if HR <60, SBP <100, acute HF"],
    ["Atorvastatin", "80 mg PO daily", "Admit orders", "High-intensity statin — start in hospital"],
    ["Lisinopril", "2.5–5 mg PO daily", "After stabilization", "Start within 24h if anterior MI or EF <40%"],
    ["tPA (alteplase)", "15 mg IV bolus, then 0.75 mg/kg x30 min, then 0.5 mg/kg x60 min", "If PCI unavailable >120 min", "Max 100 mg total; check contraindications first"],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.2, 3.2, 2.2, 5.2]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – CARDIAC: HF / Hypertensive Emergency
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "CARDIAC — Heart Failure & Hypertensive Emergency", "Acute decompensated HF and HTN urgency/emergency");

  // Left panel: acute HF
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.2, w: 6.0, h: 5.7, fill: { color: C.card }, line: { color: C.teal, pt: 1 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.2, w: 6.0, h: 0.42, fill: { color: C.teal }, line: { color: C.teal } });
  s.addText("ACUTE DECOMPENSATED HEART FAILURE", {
    x: 0.4, y: 1.22, w: 5.8, h: 0.38,
    fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", margin: 0
  });
  const hfMeds = [
    ["Furosemide", "40–80 mg IV push (double home dose)", "Diuresis; I&O monitoring"],
    ["Nitroglycerin", "10–20 mcg/min IV, titrate", "Preload reducer; watch BP"],
    ["Nitroprusside", "0.25–10 mcg/kg/min IV", "Severe HTN + HF; cyanide risk"],
    ["Morphine", "2–4 mg IV", "Reduces dyspnea (controversial)"],
    ["Dobutamine", "2.5–10 mcg/kg/min IV", "Inotrope for cardiogenic shock"],
    ["Norepinephrine", "0.01–3 mcg/kg/min IV", "Vasopressor — shock + low SVR"],
    ["Metoprolol succinate", "12.5–25 mg PO daily", "Chronic HFrEF — start low, titrate"],
    ["Lisinopril/Enalapril", "2.5–10 mg PO daily", "ACEi — first-line HFrEF"],
    ["Spironolactone", "25 mg PO daily", "HFrEF EF≤35% — monitor K+"],
    ["Sacubitril/Valsartan", "24/26 mg PO BID", "ARNI — superior to ACEi in HFrEF"],
  ];
  hfMeds.forEach(([drug, dose, note], i) => {
    const y = 1.68 + i * 0.46;
    s.addText(drug, { x: 0.4, y, w: 1.7, h: 0.42, fontSize: 9, bold: true, color: C.amber, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(dose, { x: 2.12, y, w: 2.1, h: 0.42, fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(note, { x: 4.24, y, w: 1.8, h: 0.42, fontSize: 8, color: C.slateL, fontFace: "Calibri", italic: true, margin: 0, valign: "middle" });
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    }
  });

  // Right panel: HTN emergency
  s.addShape(pres.shapes.RECTANGLE, { x: 6.55, y: 1.2, w: 6.5, h: 5.7, fill: { color: C.card }, line: { color: C.red, pt: 1 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 6.55, y: 1.2, w: 6.5, h: 0.42, fill: { color: C.red }, line: { color: C.red } });
  s.addText("HYPERTENSIVE EMERGENCY  (end-organ damage)", {
    x: 6.7, y: 1.22, w: 6.2, h: 0.38,
    fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", margin: 0
  });
  const htnMeds = [
    ["Nicardipine", "5–15 mg/hr IV drip", "1st-line; smooth, titratable"],
    ["Labetalol", "20 mg IV bolus, then 40–80 mg q10 min; or 0.5–2 mg/min drip", "Alpha+beta block; avoid asthma/COPD"],
    ["Nitroprusside", "0.25–10 mcg/kg/min IV", "Max control; cyanide risk >72h"],
    ["Hydralazine", "10–20 mg IV q4–6h", "Use in pregnancy; unpredictable"],
    ["Fenoldopam", "0.1–1.6 mcg/kg/min IV", "Good in renal impairment"],
    ["Clevidipine", "1–2 mg/hr IV, titrate", "Dihydropyridine CCB; very short acting"],
    ["Esmolol", "500 mcg/kg bolus, then 50–300 mcg/kg/min", "Aortic dissection + HTN"],
    ["Phentolamine", "5–15 mg IV", "Pheochromocytoma crisis"],
  ];
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    const y = 1.68 + i * 0.55;
    s.addText(drug, { x: 6.7, y, w: 1.6, h: 0.52, fontSize: 9, bold: true, color: C.amber, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(dose, { x: 8.32, y, w: 2.4, h: 0.52, fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(note, { x: 10.74, y, w: 2.1, h: 0.52, fontSize: 8, color: C.slateL, fontFace: "Calibri", italic: true, margin: 0, valign: "middle" });
    if (i < htnMeds.length - 1) {
      s.addShape(pres.shapes.RECTANGLE, { x: 6.65, y: y + 0.52, w: 6.3, h: 0.01, fill: { color: "1A3A5C" }, line: { color: "1A3A5C" } });
    }
  });

  s.addText("Goal: Reduce MAP by 15–25% in first hour. Do NOT normalize BP rapidly.", {
    x: 0.25, y: 6.97, w: 12.8, h: 0.3,
    fontSize: 9.5, color: C.amber, bold: true, fontFace: "Calibri", italic: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – NEUROLOGY: Stroke & Seizures
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "NEUROLOGY — Stroke & Seizures", "Time-critical orders and dosing windows");

  const headers = ["Medication", "Dose", "Indication", "Critical Note"];
  const rows = [
    ["Alteplase (tPA)", "0.9 mg/kg IV (max 90 mg)\n10% bolus, 90% over 60 min", "Ischemic stroke\n≤4.5 h window", "BP must be <185/110 before giving.\nCheck ALL contraindications first."],
    ["Labetalol", "10–20 mg IV q10 min\n(max 300 mg)", "Pre-tPA BP control", "Goal SBP <185 before tPA.\nDo NOT lower below 140."],
    ["Nicardipine", "5–15 mg/hr IV drip", "Pre-tPA BP control", "Alternative to labetalol; titratable."],
    ["Aspirin", "325 mg PO daily", "Ischemic stroke\n(no tPA or 24h post-tPA)", "Hold for 24 h if tPA was given."],
    ["Heparin (UFH)", "Per nomogram", "Cardioembolic stroke\nwith Afib", "Start 24–48 h post-stroke; bridge to DOAC."],
    ["Lorazepam", "0.1 mg/kg IV (4 mg usual adult dose)", "Acute seizure\n1st-line benzodiazepine", "Give over 2 min IV; repeat x1 if needed."],
    ["Diazepam rectal", "0.2–0.5 mg/kg PR", "Status epilepticus\n(field / no IV access)", "Prehospital or pediatric use."],
    ["Fosphenytoin", "20 PE/kg IV at 150 PE/min", "2nd-line if benzo fails", "Monitor BP and cardiac rhythm during infusion."],
    ["Levetiracetam", "1,000–3,000 mg IV load", "2nd-line or maintenance", "Fewer drug interactions than phenytoin; preferred."],
    ["Phenobarbital", "20 mg/kg IV at 60 mg/min", "3rd-line status epilepticus", "Causes sedation; watch respiratory depression."],
    ["Valproic acid", "25–45 mg/kg IV", "2nd/3rd-line SE", "Avoid in pregnancy (teratogenic) and liver disease."],
    ["Magnesium sulfate", "4–6 g IV bolus, then 1–2 g/hr", "Eclamptic seizures ONLY", "Not for epilepsy. Antidote: Calcium gluconate 1g IV."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [1.9, 2.6, 2.1, 6.2]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – SEPSIS, PNEUMONIA & MENINGITIS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "INFECTIOUS DISEASE — Sepsis, Pneumonia & Meningitis", "Empirical antibiotics by syndrome — narrow when cultures return");

  const headers = ["Syndrome", "1st-Line Regimen", "Dose", "Pearls"];
  const rows = [
    ["Sepsis — unknown source", "Piperacillin-tazobactam +\nVancomycin", "Pip-tazo 4.5 g IV q6h\nVanc 25–30 mg/kg IV load, then AUC-guided", "Blood cultures x2 BEFORE antibiotics.\nStart within 1 hour."],
    ["Septic Shock", "Add Norepinephrine", "0.01–3 mcg/kg/min IV", "1st-line vasopressor. Add hydrocortisone 200 mg/day if refractory."],
    ["CAP — outpatient (healthy)", "Azithromycin OR Doxycycline", "Azithro 500 mg PO day 1,\nthen 250 mg PO daily x4d\nDoxy 100 mg PO BID x5d", "No antibiotic if CURB-65=0 and no comorbidities (viral)."],
    ["CAP — inpatient (non-ICU)", "Ceftriaxone +\nAzithromycin\nOR Levofloxacin mono", "Ceftriaxone 1 g IV daily\nAzithro 500 mg IV/PO daily\nLevo 750 mg IV/PO daily x5d", "Coverage for typical + atypical organisms."],
    ["CAP — ICU / severe", "Ceftriaxone +\nAzithromycin OR\nRespiratory FQ", "As above, both IV", "Add coverage for Pseudomonas if risk factors."],
    ["Bacterial Meningitis", "Ceftriaxone +\nVancomycin +\nDexamethasone", "Ceftriaxone 2 g IV q12h\nVanc 15–20 mg/kg IV q8–12h\nDex 0.15 mg/kg IV q6h x4d", "Dexamethasone WITH 1st antibiotic dose.\nAdd Ampicillin 2 g IV q4h if age >50 (Listeria)."],
    ["Meningococcal prophylaxis", "Ciprofloxacin OR Rifampin", "Cipro 500 mg PO x1\nRifampin 600 mg PO BID x2d", "Treat close contacts; health dept. notification."],
    ["UTI — uncomplicated", "Nitrofurantoin OR TMP-SMX", "Nitro 100 mg PO BID x5d\nTMP-SMX DS PO BID x3d", "Avoid TMP-SMX if local resistance >20%."],
    ["Pyelonephritis — inpatient", "Ceftriaxone IV", "Ceftriaxone 1 g IV daily;\nswitch to oral when improving", "Urine + blood cultures first. Total 10–14 days."],
    ["C. diff colitis", "Vancomycin PO OR\nFidaxomicin", "Vanc 125 mg PO QID x10d\nFidaxo 200 mg PO BID x10d", "Do NOT use metronidazole (now 2nd-line/non-preferred)."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.1, 2.5, 3.3, 4.9]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – PULMONOLOGY: Asthma, COPD, PE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "PULMONOLOGY — Asthma, COPD Exacerbation & PE", "Bronchodilators, steroids, and anticoagulants");

  const headers = ["Medication", "Dose", "Indication", "Key Point"];
  const rows = [
    ["Albuterol nebulizer", "2.5 mg in 3 mL NS q20 min x3, then q4h", "Acute asthma / COPD", "Continuous neb in severe asthma; do first."],
    ["Ipratropium nebulizer", "0.5 mg q20 min x3", "Add to albuterol in severe asthma / COPD", "Added benefit only in first 24h."],
    ["Methylprednisolone IV", "125 mg IV q6h (or 1–2 mg/kg)", "Severe asthma / COPD exacerbation", "Switch to prednisone 40–60 mg PO when tolerating."],
    ["Prednisone PO", "40–60 mg PO daily x5d (COPD)\n0.5–1 mg/kg x5–7d (asthma)", "Moderate/severe exacerbation", "Taper not needed for short courses."],
    ["Magnesium sulfate IV", "2 g IV over 20 min", "Severe acute asthma (not responding to nebs)", "Single dose — smooth muscle relaxation."],
    ["Heliox", "70:30 or 80:20 helium:O2", "Refractory severe asthma", "Reduces airflow resistance; bridge to intubation."],
    ["Ketamine IV", "1–2 mg/kg IV RSI bolus", "Intubation in severe asthma", "Bronchodilator + induction agent."],
    ["Heparin (UFH)", "80 U/kg IV bolus, then 18 U/kg/hr", "Massive/submassive PE", "Start while awaiting CTPA if high suspicion."],
    ["Enoxaparin SC", "1 mg/kg SC q12h\nor 1.5 mg/kg SC daily", "PE — stable, outpatient bridge", "Adjust for renal function (CrCl <30: use UFH)."],
    ["Alteplase (tPA)", "100 mg IV over 2 hours", "Massive PE (hemodynamic instability)", "Major bleeding risk; absolute contraindications apply."],
    ["Rivaroxaban PO", "15 mg PO BID x21d, then 20 mg daily", "PE — long-term anticoagulation", "No bridging heparin needed with rivaroxaban."],
    ["Apixaban PO", "10 mg PO BID x7d, then 5 mg BID", "PE — preferred if renal impairment", "No bridging; preferred in cancer-associated VTE."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.3, 3.0, 2.5, 5.0]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – ENDOCRINOLOGY: DKA, HHS, Thyroid Storm
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "ENDOCRINOLOGY — DKA, HHS & Thyroid Storm", "Sequence matters: fluids before insulin, check K+ first");

  const headers = ["Medication", "Dose", "Indication", "Sequence / Pitfall"];
  const rows = [
    ["Normal Saline (0.9% NaCl)", "1–2 L IV over 1st hour, then 250–500 mL/hr", "DKA / HHS — STEP 1", "FLUIDS FIRST — before any insulin."],
    ["Regular Insulin IV drip", "0.1 U/kg/hr continuous IV", "DKA — STEP 2", "Only if K+ >3.5. Do NOT start if hypokalemic."],
    ["Dextrose 5% + 0.45% NaCl", "Add when glucose <250 mg/dL", "DKA — maintain glucose 150–250", "Continue insulin drip to clear ketones. Don't stop insulin early."],
    ["Potassium chloride IV", "20–40 mEq/hr IV", "K+ <5.5 in DKA (add to IV fluids)", "DKA will drop K+ dramatically once insulin starts. Replete aggressively."],
    ["Sodium bicarbonate", "1–2 mEq/kg IV over 1 hr", "DKA only if pH <6.9 + hemodynamic instability", "NOT routine — may worsen cerebral edema."],
    ["Insulin glargine / detemir", "0.2–0.3 U/kg SC at DKA resolution", "Transition off IV insulin", "Give basal insulin 2h before stopping drip."],
    ["Propylthiouracil (PTU)", "200–250 mg PO/NG q4h", "Thyroid storm — STEP 1", "Blocks synthesis AND T4→T3 conversion."],
    ["Lugol's iodine / SSKI", "5 drops PO q6h", "Thyroid storm — STEP 2", "Give 1h AFTER PTU to prevent using iodine for new hormone synthesis."],
    ["Propranolol", "60–80 mg PO q4h\nor 1–2 mg IV q5 min", "Thyroid storm — STEP 3 (rate/adrenergic)", "Controls HR, tremor, anxiety. Avoid if bronchospasm."],
    ["Dexamethasone", "2 mg IV q6h", "Thyroid storm — STEP 4 (adrenal support)", "Also blocks T4→T3 conversion."],
    ["Hydrocortisone", "100 mg IV q8h", "Adrenal crisis / adrenal insufficiency", "Stress-dose steroids. Do NOT delay for cortisol level."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.3, 2.7, 2.4, 5.4]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – OB/GYN: Pre-eclampsia, PPH, Ectopic
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "OB/GYN — Pre-eclampsia, Postpartum Hemorrhage & Ectopic Pregnancy", "Magnesium is NOT a BP drug — it is a seizure prophylactic");

  const headers = ["Medication", "Dose", "Indication", "Key CCS Point"];
  const rows = [
    ["Magnesium sulfate", "4–6 g IV load over 20 min,\nthen 1–2 g/hr maintenance", "Pre-eclampsia with severe features + eclampsia", "Seizure prophylaxis AND treatment.\nCa gluconate 1g IV = antidote at bedside."],
    ["Labetalol IV", "20 mg IV q10 min (max 300 mg)", "Acute severe HTN in pregnancy (BP ≥160/110)", "Hold if maternal HR <60 or asthma."],
    ["Hydralazine IV", "5–10 mg IV q20 min (max 30 mg)", "Acute severe HTN in pregnancy", "Slower onset; unpredictable — use labetalol first."],
    ["Nifedipine PO", "10–20 mg PO q20 min", "Acute HTN in pregnancy (oral option)", "Do NOT use sublingual (severe hypotension)."],
    ["Betamethasone IM", "12 mg IM q24h x2 doses", "Fetal lung maturity <34 weeks", "Order at 24–34 weeks with risk of preterm delivery."],
    ["Oxytocin", "10–40 units in 1L NS IV\nor 10 units IM", "Postpartum hemorrhage (PPH) — 1st-line", "Uterotonic; order immediately after delivery."],
    ["Methylergonovine (Methergine)", "0.2 mg IM q2–4h", "PPH if oxytocin insufficient", "CONTRAINDICATED in HTN — raises BP."],
    ["Misoprostol", "800–1000 mcg rectal/sublingual", "PPH — 2nd-line uterotonic", "Safe in HTN (unlike Methergine)."],
    ["Methotrexate IM", "50 mg/m2 IM single dose", "Ectopic pregnancy — stable, unruptured", "Check beta-hCG on days 4 and 7 post-MTX."],
    ["RhoGAM (anti-D Ig)", "300 mcg IM within 72 hours", "Rh-negative mother: ectopic, miscarriage, trauma, delivery", "Prevents Rh sensitization. Check Rh on ALL pregnant patients."],
    ["Terbutaline SC", "0.25 mg SC q20 min x3 doses", "Preterm labor tocolysis (short-term)", "Used to give steroids time to work — not long-term."],
    ["GBS prophylaxis (Penicillin G)", "5 million units IV, then 2.5M U IV q4h", "GBS-positive mother at delivery", "Alternative: Ampicillin. Allergy: Clindamycin or Vancomycin."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.2, 2.8, 2.8, 5.0]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – PSYCHIATRY & TOXICOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "PSYCHIATRY & TOXICOLOGY — Overdoses, Agitation & Antidotes", "Antidotes are CCS gold — know each one cold");

  // Split: left = psych meds, right = antidotes
  const headers = ["Toxin / Condition", "Drug", "Dose", "Notes"];
  const rows = [
    ["Opioid overdose", "Naloxone (Narcan)", "0.4–2 mg IV/IM/IN q2–3 min", "Titrate to respiratory rate, not full reversal (avoid withdrawal)"],
    ["Benzodiazepine OD", "Supportive only\n(NOT flumazenil)", "Flumazenil 0.2 mg IV x1 ONLY if no benzo dependence", "Flumazenil → seizures if benzo-dependent. Use rarely."],
    ["TCA overdose", "Sodium bicarbonate", "1–2 mEq/kg IV bolus; drip to pH 7.45–7.55", "Widens QRS: give bicarb immediately. Avoid physostigmine."],
    ["Acetaminophen OD", "N-Acetylcysteine (NAC)", "150 mg/kg IV over 1h, then 50 mg/kg over 4h, then 100 mg/kg over 16h", "Give even if Rumack-Matthew line not reached if >150 mg/kg ingested."],
    ["Salicylate (ASA) OD", "Sodium bicarbonate", "IV drip to alkalinize urine pH >7.5; hemodialysis if severe", "Order bicarb + check salicylate level q2h."],
    ["CO poisoning", "100% O2 via NRB mask", "Hyperbaric O2 if LOC, cardiac symptoms, or >25% COHb", "Do NOT go by O2 sat (pulse ox reads false normal)."],
    ["Organophosphate OD", "Atropine + Pralidoxime", "Atropine 2–4 mg IV q5–10 min until secretions dry\nPralidoxime 1–2 g IV over 15–30 min", "Atropine for muscarinic sx; Pralidoxime reverses acetylcholinesterase inhibition."],
    ["Heparin OD", "Protamine sulfate", "1 mg per 100 U heparin given (max 50 mg) IV slowly", "Watch for anaphylaxis."],
    ["Warfarin OD / bleeding", "Vitamin K + 4-factor PCC", "Vit K 10 mg IV slow + 4F-PCC 25–50 U/kg for urgent reversal", "FFP if PCC unavailable. Use for INR >10 or active bleeding."],
    ["Acute agitation (ED)", "Droperidol OR Haloperidol OR Ziprasidone IM", "Droperidol 5 mg IM; Haloperidol 5 mg IM; Lorazepam 2 mg IM", "Combative: IM preferred. Do ECG (QTc). Chemical restraint."],
    ["Alcohol withdrawal", "Lorazepam OR Diazepam", "Lorazepam 2–4 mg IV/PO q6h PRN CIWA\nDiazepam 10–20 mg PO/IV q6h", "CIWA-Ar score guides dosing. Give thiamine 100 mg IV BEFORE glucose."],
    ["NMS (Neuroleptic Malignant Syndrome)", "Dantrolene + Bromocriptine", "Dantrolene 1–2.5 mg/kg IV q6h\nBromocriptine 2.5 mg PO TID", "Stop offending antipsychotic immediately. ICU cooling."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.3, 2.2, 3.0, 5.3]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – GI, RENAL & PAIN
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "GI, RENAL & PAIN MANAGEMENT", "GI bleeds, hepatic encephalopathy, acute kidney injury, and analgesia");

  const headers = ["Condition", "Medication", "Dose", "Notes"];
  const rows = [
    ["Upper GI bleed", "Pantoprazole (PPI) IV", "80 mg IV bolus, then 8 mg/hr infusion", "Start before endoscopy. NGT lavage to assess activity."],
    ["Variceal bleed", "Octreotide IV +\nCeftriaxone IV prophylaxis", "Octreotide 50 mcg bolus, then 50 mcg/hr\nCeftriaxone 1 g IV daily x7d", "Vasoconstricts portal flow. Do NOT use vasopressin alone."],
    ["Hepatic encephalopathy", "Lactulose PO/NG +\nRifaximin", "Lactulose 30–45 mL PO TID–QID (titrate to 2–4 BM/day)\nRifaximin 550 mg PO BID", "Lactulose acidifies colon, traps NH3. Rifaximin reduces gut flora."],
    ["C. diff (moderate)", "Vancomycin PO", "125 mg PO QID x10 days", "Metronidazole no longer preferred for initial treatment."],
    ["Pancreatitis", "IV crystalloid +\nAnalgesia", "LR 250–500 mL/hr (preferred over NS)\nHydromorphone or morphine IV PRN", "NPO, IVF, pain control. Antibiotics only for infected necrosis."],
    ["Acute kidney injury", "IV saline (isotonic) +\nFurosemide PRN", "NS or LR 1–2 L IV challenge\nFurosemide 40–80 mg IV if fluid overloaded", "Foley catheter for UO monitoring. Hold nephrotoxins."],
    ["Hyperkalemia (K+ >6.5 or ECG changes)", "Calcium gluconate IV +\nInsulin + D50 +\nSodium bicarb +\nKayexalate / Patiromer", "Ca gluconate 1 g IV over 5 min (immediate cardiac protection)\nInsulin 10 U + D50 50 mL IV (shifts K+)\nBicarb 50 mEq IV, Kayexalate 30 g PO", "Calcium FIRST for cardiac protection, then shifts, then excretion."],
    ["Gout flare", "Colchicine OR\nIndomethacin OR\nPrednisone", "Colchicine 1.2 mg PO, then 0.6 mg 1h later\nIndomethacin 50 mg PO TID x5d\nPrednisone 30–40 mg PO x5d", "NSAIDs first-line unless renal impairment or elderly. Allopurinol: do NOT start during acute flare."],
    ["Post-op pain", "Ketorolac IV +\nAcetaminophen IV", "Ketorolac 15–30 mg IV q6h (max 5 days)\nAcetaminophen 1000 mg IV q6h", "Multimodal analgesia reduces opioid use."],
    ["Acute pain (moderate-severe)", "Morphine IV", "2–4 mg IV q2–4h PRN\nor 0.1 mg/kg IV", "Always reassess pain score after giving. Monitor respiratory rate."],
    ["DVT prophylaxis (hospitalized)", "Enoxaparin SC", "40 mg SC daily (CrCl >30)\nor 30 mg SC daily (ortho post-op)", "Order on admission. Add compression stockings."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.3, 2.3, 3.0, 5.2]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – PEDIATRICS HIGH-YIELD MEDS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "PEDIATRICS — High-Yield Medications & Dosing", "Weight-based dosing — always write mg/kg on CCS");

  const headers = ["Condition", "Medication", "Pediatric Dose", "CCS Pitfall"];
  const rows = [
    ["Febrile seizure / status epilepticus", "Lorazepam IV\nor Diazepam rectal", "Lorazepam 0.1 mg/kg IV (max 4 mg)\nDiazepam 0.2–0.5 mg/kg PR (max 10 mg)", "Benzo first, then fosphenytoin if fails. Do NOT give phenytoin IV rapidly."],
    ["Bacterial meningitis", "Ceftriaxone IV +\nVancomycin IV +\nDexamethasone IV", "Ceftriaxone 100 mg/kg/day IV div q12h (max 4g)\nVanc 15 mg/kg IV q6h\nDex 0.15 mg/kg IV q6h x4d", "Dex before/with first antibiotic dose reduces deafness."],
    ["Otitis media (>2 yrs)", "Amoxicillin PO", "80–90 mg/kg/day PO div BID (max 3g/day)", "High-dose amox overcomes resistant S. pneumo. 5–7 day course."],
    ["Strep pharyngitis", "Penicillin V PO", "250 mg PO BID-TID (<27 kg)\n500 mg PO BID-TID (>27 kg) x10d", "Amoxicillin 50 mg/kg/day also acceptable. Prevent rheumatic fever."],
    ["RSV bronchiolitis", "Supportive: O2 +\nBulb suction + fluids", "No specific antiviral; O2 goal >92%", "Do NOT give albuterol, steroids, or antibiotics routinely."],
    ["Nephrotic syndrome", "Prednisone PO", "2 mg/kg/day PO (max 60 mg) for 4–6 weeks,\nthen taper", "First step is corticosteroids. Albumin + furosemide for symptomatic edema."],
    ["Kawasaki disease", "Aspirin (high-dose) +\nIVIG", "Aspirin 80–100 mg/kg/day PO div q6h (acute phase)\nIVIG 2 g/kg IV single dose over 8–12h", "Start within 10 days of fever onset to prevent coronary aneurysm."],
    ["Croup", "Dexamethasone PO/IM +\nRacemic epinephrine neb", "Dex 0.6 mg/kg IM/PO x1\nRacemic epi 0.5 mL of 2.25% in 3 mL NS", "Racemic epi: observe 2h after dose for rebound."],
    ["Epiglottitis", "Ceftriaxone IV +\nIntubation readiness", "Ceftriaxone 50 mg/kg IV q24h (max 2g)", "Do NOT attempt to visualize — may precipitate obstruction. OR intubation."],
    ["Fever/antipyresis", "Ibuprofen PO\nor Acetaminophen PO", "Ibuprofen 10 mg/kg/dose PO q6–8h (>6 mo)\nAcetaminophen 15 mg/kg/dose PO q4–6h", "Aspirin contraindicated <18 yrs (Reye's syndrome)."],
  ];

  addTableSlide(s, headers, rows, 0.25, 1.25, 12.8, [2.2, 2.3, 3.1, 5.2]);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – MUST-KNOW ANTIDOTES & REVERSAL AGENTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "MUST-KNOW ANTIDOTES & REVERSAL AGENTS", "Every CCS antidote question rewards the prepared candidate");

  const antidotes = [
    ["Opioids", "Naloxone", "0.4–2 mg IV/IM/IN q2–3 min"],
    ["Benzos", "Flumazenil (caution)", "0.2 mg IV q1 min; avoid if benzo-dependent"],
    ["Acetaminophen", "N-Acetylcysteine", "150 mg/kg IV over 1h → 50 mg/kg/4h → 100 mg/kg/16h"],
    ["TCA", "Sodium Bicarbonate", "1–2 mEq/kg IV bolus; drip pH 7.45–7.55"],
    ["Heparin (UFH)", "Protamine Sulfate", "1 mg per 100 U heparin (max 50 mg IV)"],
    ["Warfarin bleed", "Vit K + 4F-PCC / FFP", "Vit K 10 mg IV + PCC 25–50 U/kg IV"],
    ["Dabigatran bleed", "Idarucizumab", "5 g IV (2 x 2.5 g) — specific reversal"],
    ["Rivaroxaban/Apixaban bleed", "Andexanet alfa", "Low dose: 400 mg IV over 15 min + 4 mg/min x2h"],
    ["Beta-blocker OD", "Glucagon", "3–5 mg IV bolus, then 3–5 mg/hr infusion"],
    ["CCB OD", "Calcium gluconate +\nHigh-dose insulin", "CaGluc 1–3 g IV; Insulin 1 U/kg bolus + 1 U/kg/hr + D50"],
    ["Digoxin toxicity", "Digoxin-specific Fab antibody (Digibind)", "Dose based on serum dig level or estimated ingestion"],
    ["CO poisoning", "100% O2 (NRB); HBO if severe", "COHb half-life: 5h on room air → 60–90 min on 100% O2"],
    ["Cyanide poisoning", "Hydroxocobalamin", "5 g IV over 15 min; antidote kit: amyl nitrite + Na thiosulfate"],
    ["Iron OD", "Deferoxamine", "15 mg/kg/hr IV continuous (max 6 g/day)"],
    ["Organophosphate", "Atropine + Pralidoxime", "Atropine 2–4 mg IV until secretions dry; 2-PAM 1–2 g IV"],
    ["Methanol/Ethylene glycol", "Fomepizole (or EtOH)", "15 mg/kg IV load, then 10 mg/kg q12h"],
    ["Isoniazid (INH) OD", "Pyridoxine (Vit B6)", "1g IV per gram of INH ingested (or 5g IV if unknown)"],
    ["Magnesium toxicity", "Calcium Gluconate", "1 g (10 mL of 10%) IV over 5 min"],
  ];

  // Two columns of cards
  const half = Math.ceil(antidotes.length / 2);
  antidotes.forEach(([toxin, antidote, dose], i) => {
    const col = i < half ? 0 : 1;
    const row = i < half ? i : i - half;
    const x = col === 0 ? 0.25 : 6.7;
    const y = 1.25 + row * 0.535;
    const w = 6.2;
    const h = 0.5;

    const bg = row % 2 === 0 ? C.card : "132840";
    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h, fill: { color: bg }, line: { color: "1A3A5C" } });
    s.addText(toxin, { x: x + 0.1, y, w: 1.5, h, fontSize: 9, bold: true, color: C.amber, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(antidote, { x: x + 1.62, y, w: 1.8, h, fontSize: 9, bold: true, color: C.tealLt, fontFace: "Calibri", margin: 0, valign: "middle" });
    s.addText(dose, { x: x + 3.44, y, w: 2.6, h, fontSize: 8, color: C.offWhite, fontFace: "Calibri", margin: 0, valign: "middle" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – DISCHARGE MEDS & COUNSELING CHECKLIST
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "DISCHARGE MEDICATIONS & COUNSELING CHECKLIST", "These orders earn points even in the final minutes of the case");

  const scenarios = [
    {
      title: "Post-MI Discharge",
      color: C.red,
      items: [
        "Aspirin 81 mg PO daily (lifelong)",
        "Clopidogrel/Ticagrelor PO daily x12 months (DAPT)",
        "Metoprolol succinate or carvedilol PO daily",
        "Lisinopril/ramipril PO daily (if EF<40% or anterior MI)",
        "Atorvastatin 80 mg PO nightly",
        "Nitroglycerin SL PRN chest pain (patient education)",
        "Cardiac rehab referral",
        "Smoking cessation counseling",
      ]
    },
    {
      title: "Post-Stroke Discharge",
      color: C.teal,
      items: [
        "Aspirin 81 mg PO daily (if no cardioembolic source)",
        "DOAC (rivaroxaban/apixaban) if Afib found",
        "High-intensity statin (atorvastatin 80 mg nightly)",
        "Antihypertensive therapy (ACEi preferred)",
        "PT, OT, speech therapy referrals",
        "Dysphagia screen before any oral intake",
        "DVT prophylaxis during admission",
      ]
    },
    {
      title: "Post-Sepsis/Infection",
      color: C.amber,
      items: [
        "Oral antibiotic at discharge (culture-directed)",
        "Follow-up in 48–72h (blood cultures, wound check)",
        "Pneumococcal vaccine if indicated",
        "Influenza vaccine if seasonal",
        "Smoking cessation",
        "Return precautions: fever >38.5, chills, worsening symptoms",
      ]
    },
    {
      title: "Pre-eclampsia Post-partum",
      color: "9333EA",
      items: [
        "Continue MgSO4 x24–48h post-delivery",
        "Labetalol or nifedipine PO for BP control",
        "Monitor BP daily x72h post-partum",
        "OB follow-up in 1 week",
        "Long-term cardiovascular risk counseling",
        "Aspirin 81 mg in future pregnancies (risk reduction)",
      ]
    },
  ];

  scenarios.forEach(({ title, color, items }, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.25 : 6.9;
    const y = row === 0 ? 1.25 : 4.25;
    const w = 6.2;
    const h = 2.75;

    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h, fill: { color: C.card }, line: { color, pt: 1.5 }, rectRadius: 0.1 });
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h: 0.38, fill: { color }, line: { color }, rectRadius: 0.1 });
    s.addShape(pres.shapes.RECTANGLE, { x, y: y + 0.2, w, h: 0.18, fill: { color }, line: { color } });
    s.addText(title, { x: x + 0.15, y: y + 0.05, w: w - 0.3, h: 0.3, fontSize: 10.5, bold: true, color: C.white, fontFace: "Calibri", margin: 0 });

    const textItems = items.map((item, idx) => ({
      text: `• ${item}`,
      options: { breakLine: idx < items.length - 1, fontSize: 9, color: C.offWhite, fontFace: "Calibri" }
    }));
    s.addText(textItems, { x: x + 0.15, y: y + 0.45, w: w - 0.3, h: h - 0.55, valign: "top", margin: 0 });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 – TOP 10 MEDICATION PITFALLS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.navy };
  addSlideTitle(s, "TOP 10 MEDICATION PITFALLS ON CCS", "Each of these mistakes has cost examinees points — memorize them");

  const pitfalls = [
    ["1", "Starting insulin BEFORE checking K+ in DKA", "Hypokalemia + insulin → fatal arrhythmia. Always check K+ first. Hold insulin if K+ <3.5."],
    ["2", "Ordering antibiotics BEFORE blood/CSF cultures", "Cultures after antibiotics are useless. Draw cultures, THEN give antibiotics (within seconds on CCS)."],
    ["3", "Giving nitrates in RV infarction (inferior STEMI)", "No preload = no cardiac output. Always get right-sided leads (V4R) for inferior STEMI first."],
    ["4", "Giving tPA without checking BP first", "BP must be <185/110. Treat with labetalol/nicardipine if needed. Skipping this = major bleed."],
    ["5", "Lowering BP too aggressively in ischemic stroke", "Target MAP reduction ≤15% only if giving tPA. Otherwise, allow permissive hypertension."],
    ["6", "Using flumazenil in benzodiazepine-dependent patients", "Precipitates seizures. Only use for pure procedural benzo overdose with no dependence."],
    ["7", "Using methergine (methylergonovine) in hypertensive patients with PPH", "Causes severe vasoconstriction. Use misoprostol or oxytocin instead."],
    ["8", "Not giving dexamethasone WITH first antibiotic dose in meningitis", "Dex reduces neurological sequelae (especially deafness). Timing is critical."],
    ["9", "Starting allopurinol during an acute gout flare", "Worsens the flare. Use colchicine/NSAIDs/prednisone acutely; start allopurinol only after resolution."],
    ["10", "Skipping counseling and follow-up orders before case ends", "CCS awards points for counseling, vaccine orders, and follow-up. Add these before advancing final clock."],
  ];

  pitfalls.forEach(([num, title, body], i) => {
    const col = i < 5 ? 0 : 1;
    const row = i < 5 ? i : i - 5;
    const x = col === 0 ? 0.25 : 6.75;
    const y = 1.25 + row * 1.18;
    const w = 6.2;
    const h = 1.1;

    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w, h, fill: { color: C.card }, line: { color: C.red, pt: 1 }, rectRadius: 0.08 });
    s.addShape(pres.shapes.OVAL, { x: x + 0.1, y: y + 0.15, w: 0.5, h: 0.5, fill: { color: C.red }, line: { color: C.red } });
    s.addText(num, { x: x + 0.1, y: y + 0.15, w: 0.5, h: 0.5, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", margin: 0 });
    s.addText(title, { x: x + 0.7, y: y + 0.06, w: w - 0.85, h: 0.36, fontSize: 10, bold: true, color: C.amber, fontFace: "Calibri", margin: 0 });
    s.addText(body, { x: x + 0.7, y: y + 0.42, w: w - 0.85, h: 0.6, fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", margin: 0, valign: "top" });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ══════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/step3-ccs-meds/Step3_CCS_HighYield_Medications.pptx" })
  .then(() => console.log("✅ Presentation saved successfully!"))
  .catch(err => console.error("❌ Error:", err));

Running Command

cd /home/daytona/workspace/step3-ccs-meds && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/step3-ccs-meds/Step3_CCS_HighYield_Medications.pp…

Your presentation is ready:

Step3 CCS HighYield Medications

Presentation · PPTX

What's inside (15 slides, dark navy + teal theme):

Slide	Content
1	Cover slide with category overview
2	CCS Scoring Strategy - why meds matter and how they're graded
3	Cardiac - ACS / STEMI - aspirin, heparin, tPA, P2Y12 inhibitors, beta-blockers, statins
4	Cardiac - Heart Failure & HTN Emergency - furosemide, vasodilators, inotropes, titratable IV agents
5	Neurology - Stroke & Seizures - alteplase dosing window, benzodiazepine ladder, anti-epileptics
6	Infectious Disease - Sepsis, Pneumonia & Meningitis - empirical regimens with specific doses
7	Pulmonology - Asthma, COPD & PE - bronchodilators, steroids, anticoagulation (DOAC dosing included)
8	Endocrinology - DKA, HHS & Thyroid Storm - fluids-before-insulin sequence, thyroid storm 4-step protocol
9	OB/GYN - Pre-eclampsia, PPH & Ectopic - magnesium protocol, uterotonics, methotrexate, RhoGAM
10	Psychiatry & Toxicology - overdose management and antidotes
11	GI, Renal & Pain - GI bleeds, hepatic encephalopathy, hyperkalemia, analgesia
12	Pediatrics - weight-based dosing for all common pediatric emergencies
13	Master Antidotes Table - 18 antidotes with full doses in two-column layout
14	Discharge Medication Checklists - post-MI, post-stroke, post-sepsis, pre-eclampsia
15	Top 10 Medication Pitfalls - the exact mistakes that lose CCS points

Medications and treatment must know for step 3 exam

Reading File

Finding Sources

Finding Sources

Finding Sources

Finding Sources

Finding Sources

Finding Sources

Finding Sources

Finding Sources

That's your complete Step 3 medication and treatment reference, organized into 13 sections:

Cardiology - HTN compelling indications, GDMT for HF, ACS/STEMI MONA-BASH, antiarrhythmics
Endocrinology - DM2 algorithm, insulin types, thyroid storm protocol, adrenal disorders
Pulmonology - Asthma step therapy, COPD pharmacotherapy
Infectious Disease - CAP, UTI, STI, HIV, TB antibiotic selection
Neurology - Seizure ladder, migraine acute vs. preventive, Parkinson's, dementia
Psychiatry - SSRIs, bipolar, schizophrenia, EPS management, anxiety/OCD
Gastroenterology - GI bleeds, IBD, hepatic encephalopathy, C. diff
Nephrology - CKD, hyperkalemia, SIADH, gout, nephrolithiasis
Hematology/Oncology - Anemias, HIT, VTE, TTP, ITP
Rheumatology - RA, SLE, osteoporosis, GCA
OB/GYN - Prenatal care, pre-eclampsia, PPH, ectopic pregnancy
Drug Interactions & Contraindications - The pitfalls that generate MCQ traps
Rapid Review First-Line Drug List - 50+ must-know "drug of choice" pairings

Step 3 high yield nutrition

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Excellent data from Harrison's, Robbins, and multiple authoritative sources. Now I have everything I need.

High-Yield Nutrition for USMLE Step 3

PART 1: VITAMIN DEFICIENCIES

Fat-Soluble Vitamins (A, D, E, K)

(Absorbed with dietary fat — ALL are lost in fat malabsorption states: cholestatic liver disease, cystic fibrosis, Crohn's of terminal ileum, celiac disease, bariatric surgery)

Vitamin A (Retinol)

Functions: Night vision (rhodopsin synthesis), epithelial integrity, immune function, embryonic development

Deficiency signs:

Early: Night blindness (nyctalopia) - first and most sensitive sign
Progressive: Xerophthalmia (dry eyes), Bitot's spots (foamy white plaques on conjunctiva), corneal ulceration → blindness
Skin: follicular hyperkeratosis ("toad skin")
Immune: increased susceptibility to infections (especially measles and respiratory infections)

At-risk populations: Developing countries, alcoholics, fat malabsorption syndromes, protein-energy malnutrition (retinol-binding protein requires protein)

Treatment: Vitamin A supplementation; prophylactic vitamin A given in developing countries during measles to reduce mortality

Toxicity (Hypervitaminosis A):

Acute: headache, vomiting, increased ICP (pseudotumor cerebri)
Chronic: alopecia, dry skin, hepatotoxicity, hypercalcemia, bone pain
Teratogenic - causes neural tube defects and craniofacial anomalies (avoid isotretinoin/high-dose vitamin A in pregnancy)

Vitamin D (Cholecalciferol)

Activation pathway: Skin (UV light) → D3 (cholecalciferol) → liver (25-hydroxylation → 25-OH-D, the storage form measured in serum) → kidney (1-alpha-hydroxylation → 1,25-OH-D = calcitriol, the active form)

Functions: Calcium and phosphorus absorption from gut; mineralization of bone; immune modulation

Deficiency causes:

Lack of sun exposure (elderly, institutionalized, dark skin)
Fat malabsorption
Chronic kidney disease (cannot 1-alpha-hydroxylate → use calcitriol, not D3)
Chronic liver disease (cannot 25-hydroxylate → give D3 supplements)
Anticonvulsants (phenytoin, phenobarbital → accelerate D catabolism)
Strict veganism (D2 only in plants)

Clinical manifestations:

Children: Rickets - craniotabes, rachitic rosary (costochondral beading), frontal bossing, Harrison's groove, bowlegged (genu varum) or knock-knee (genu valgum), delayed dentition
Adults: Osteomalacia - diffuse bone pain, muscle weakness, pathological fractures, Looser's zones (pseudofractures on X-ray)
Labs: low calcium, low phosphorus, high PTH, high alkaline phosphatase, low 25-OH vitamin D

Treatment:

Deficiency (25-OH D <20 ng/mL): ergocalciferol (D2) or cholecalciferol (D3) 50,000 IU PO weekly x8-12 weeks, then maintenance 1,500-2,000 IU/day
CKD: calcitriol (active form) - do NOT use regular D3 (kidney cannot activate it)

Vitamin E (Tocopherol)

Functions: Antioxidant (protects cell membranes from lipid peroxidation), synergizes with selenium

Deficiency: Only occurs with fat malabsorption or genetic abnormalities (abetalipoproteinemia)

Clinical signs:

Spinocerebellar ataxia (degenerative)
Peripheral neuropathy (loss of deep tendon reflexes, proprioception)
Skeletal muscle atrophy
Retinopathy
Hemolytic anemia in premature infants

Key association: Abetalipoproteinemia (cannot absorb fat-soluble vitamins) → acanthocytes + fat malabsorption + vitamin E deficiency → progressive neurological deterioration in childhood

Vitamin K

Functions: Cofactor for gamma-carboxylation of clotting factors II, VII, IX, X (and proteins C and S)

Made by gut bacteria; found in green leafy vegetables

Deficiency causes:

Newborns (sterile gut, poor placental transfer, low breast milk content) → hemorrhagic disease of the newborn - prevented by vitamin K IM at birth
Parents who refuse IM Vit K at birth: 81x higher risk of bleeding
Fat malabsorption
Prolonged antibiotic use (kills gut flora)
Warfarin, salicylates, cholestyramine

Clinical signs: Elevated PT/INR, bleeding (ecchymoses, GI bleed, intracranial hemorrhage in neonates)

Step 3 facts:

PT is prolonged BEFORE aPTT in vitamin K deficiency (factor VII has shortest half-life)
Treatment: vitamin K IM for several days; FFP in acute crises
Warfarin reversal: vitamin K + 4-factor PCC (Kcentra)

Water-Soluble Vitamins (B-complex + C)

(Not stored - regular intake required; excess excreted in urine)

Vitamin B1 - Thiamine

Function: Cofactor for pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase, transketolase (pentose phosphate pathway)

High-risk groups: Alcoholics (most common in US), bariatric surgery patients, ICU patients, hyperemesis gravidarum, patients on prolonged IV glucose without thiamine supplementation

CRITICAL RULE: Give thiamine BEFORE glucose/dextrose in any malnourished/alcoholic patient - glucose without thiamine precipitates acute Wernicke encephalopathy

Deficiency syndromes:

Syndrome	Features
Dry beriberi	Peripheral neuropathy - symmetric ascending motor/sensory; muscle weakness and wasting
Wet beriberi	High-output cardiac failure, cardiomegaly, edema, dyspnea
Wernicke encephalopathy	Classic triad: confusion + ophthalmoplegia (lateral gaze palsy/nystagmus) + ataxia
Wernicke-Korsakoff syndrome	Wernicke + amnestic confabulatory state (Korsakoff) - anterograde amnesia, confabulation; mammillary body damage on MRI

Treatment: Thiamine 100 mg IV/IM immediately; Korsakoff may be irreversible

Vitamin B2 - Riboflavin

Function: Component of FAD and FMN coenzymes; energy metabolism

Deficiency causes: Alcoholism, poor dairy/meat intake

Clinical signs ("2 C's + 2 D's"):

Cheilosis (cracking at corners of mouth)
Corneal vascularization
Dermatitis (seborrheic)
Diarrhea
Magenta (glossy red) tongue, angular stomatitis, photophobia

Vitamin B3 - Niacin (Nicotinic Acid)

Function: Component of NAD+ and NADP+ (essential for redox reactions); synthesized from tryptophan

Deficiency causes:

Alcoholism
Isoniazid (INH) treatment (depletes B6 which is needed for niacin synthesis)
Hartnup disease (tryptophan malabsorption)
Carcinoid syndrome (tryptophan diverted to serotonin)
Corn-based diets (corn is low in niacin and tryptophan; niacin in corn is bound - not bioavailable)

Pellagra - "3 D's + 1 more D":

Dermatitis: hyperpigmented, scaly rash on sun-exposed skin (Casal's necklace around neck), symmetrical
Diarrhea
Dementia (confusion, memory loss, disorientation, psychosis)
Death (if untreated)

Treatment: Nicotinamide (niacinamide) or niacin supplementation

Niacin toxicity (pharmacologic doses used for dyslipidemia):

Flushing (prostaglandin-mediated; prevent with aspirin 30 min before or use extended-release)
Hepatotoxicity (extended-release form > immediate release)
Hyperglycemia
Hyperuricemia (gout)
Pruritus

Vitamin B6 - Pyridoxine

Function: Cofactor for aminotransferases, decarboxylases, heme synthesis, neurotransmitter synthesis (GABA, serotonin, dopamine)

Deficiency causes:

Isoniazid (INH) - most tested cause; INH is a structural analog that depletes B6 → give pyridoxine 25-50 mg/day with all INH regimens
Alcoholism
Oral contraceptives (rare)

Clinical signs:

Peripheral neuropathy
Seborrheic dermatitis, glossitis
Sideroblastic anemia (microcytic; iron cannot be incorporated into heme)
Seizures (in infants)
Depression, confusion

Toxicity (high doses >200 mg/day): Sensory neuropathy (irreversible), ataxia

Vitamin B9 - Folate (Folic Acid)

Function: One-carbon transfer reactions; DNA synthesis (thymidylate synthesis); purine synthesis; methionine synthesis

Deficiency causes:

Alcoholism (most common in US)
Poor diet (elderly, poverty)
Pregnancy (increased demand)
Methotrexate (DHFR inhibitor - blocks folate activation)
Trimethoprim (DHFR inhibitor)
Sulfasalazine, pyrimethamine, triamterene (folate antagonists)
Phenytoin (impairs absorption)
Celiac disease (proximal small bowel absorption)

Clinical signs:

Megaloblastic anemia (large RBCs, hypersegmented neutrophils ≥5 lobes)
Glossitis (smooth, beefy red tongue), cheilosis
Elevated homocysteine (but NORMAL methylmalonic acid - distinguishes from B12)
NO neurological symptoms (unlike B12 deficiency)

Supplementation:

All women of childbearing age: 400-800 mcg/day folic acid
Prior neural tube defect: 4 mg/day starting 1-3 months before conception
Prevents: neural tube defects (spina bifida, anencephaly), cleft lip/palate

Vitamin B12 - Cobalamin

Absorption pathway: Dietary B12 → stomach acid releases B12 from food → intrinsic factor (IF) secreted by gastric parietal cells binds B12 → B12-IF complex absorbed in terminal ileum

Deficiency causes:

Pernicious anemia - autoimmune destruction of parietal cells → no IF → B12 malabsorption (anti-parietal cell and anti-IF antibodies)
Strict vegetarianism/veganism (B12 only in animal products)
Gastrectomy / bariatric surgery (no parietal cells → no IF)
Terminal ileal disease or resection (Crohn's, ileal resection)
Metformin (reduces absorption by up to 30% - check B12 annually)
Acid suppression (H2 blockers, PPIs) - impairs release from food-bound form
Fish tapeworm (Diphyllobothrium latum) - competes for B12
Nitrous oxide exposure (inactivates B12 irreversibly)

Clinical signs:

Megaloblastic anemia (same as folate)
Subacute combined degeneration of the spinal cord:
- Posterior columns (dorsal): loss of vibration, proprioception, Romberg positive
- Lateral columns: upper motor neuron signs (spasticity, hyperreflexia, Babinski)
- Combined = both UMN and LMN signs
Dementia, depression, psychosis ("megaloblastic madness")
Glossitis (smooth tongue)
Elevated methylmalonic acid AND homocysteine (distinguishes from folate - folate deficiency has normal MMA)

Step 3 key point: Giving folate to a B12-deficient patient corrects the anemia but DOES NOT stop neurological progression - always check B12 before treating megaloblastic anemia.

Treatment:

Pernicious anemia: cyanocobalamin 1,000 mcg IM daily x7d → weekly x4 → monthly (lifelong)
Dietary deficiency: high-dose oral B12 1,000 mcg/day (effective even without IF via passive absorption)

Vitamin C - Ascorbic Acid

Functions: Collagen synthesis (hydroxylation of proline/lysine), antioxidant, iron absorption (reduces Fe3+ to Fe2+), immune function

Deficiency causes: Alcoholism, smoking (increased oxidative demand), elderly on limited diets, patients on all-liquid/IV-only nutrition

Scurvy - clinical features:

Perifollicular petechiae and corkscrew/coiled hairs (pathognomonic)
Bleeding gums (gingivitis, periungual hemorrhage)
Subperiosteal hemorrhage → bone pain in children
Poor wound healing
Hemarthrosis (joint bleeding)
Anemia (iron malabsorption + bleeding)
Fatigue, depression

X-ray in children: Trümmerfeld zone (zone of destruction), Pelkan spurs, "white line of Fraenkel"

Treatment: Vitamin C 100-300 mg PO TID; symptoms resolve rapidly

PART 2: TRACE ELEMENT DEFICIENCIES

Element	Functions	Deficiency Cause	Clinical Features
Zinc	Enzyme component (oxidases), gene expression regulation, immune function	TPN without zinc supplementation, malabsorption, alcoholism, Crohn's	Acrodermatitis enteropathica (rash around mouth, nose, eyes, anus); alopecia; poor wound healing; impaired immunity; hypogonadism; dysgeusia (taste loss); growth retardation; diarrhea
Iron	Hemoglobin, myoglobin, cytochromes	Chronic blood loss, inadequate diet, malabsorption, pregnancy	Hypochromic microcytic anemia, fatigue, pica, koilonychia (spoon nails), glossitis, angular cheilitis, Plummer-Vinson syndrome (esophageal webs)
Iodine	Thyroid hormone synthesis	Inadequate intake (inland/mountainous areas), goitrogenic foods	Goiter, hypothyroidism; fetal deficiency → cretinism (intellectual disability, deafness, stunted growth)
Copper	Cytochrome c oxidase, collagen cross-linking, dopamine synthesis, melanin production	TPN without copper, zinc excess (competitive inhibition), Menkes disease	Microcytic anemia (ring sideroblasts), muscle weakness, peripheral neuropathy, abnormal collagen (resembles scurvy), osteoporosis
Selenium	Component of glutathione peroxidase; antioxidant with Vit E	Soil depleted in selenium (parts of China), TPN	Keshan disease (dilated cardiomyopathy), myopathy
Fluoride	Enamel mineralization	Deficient water supply	Dental caries
Magnesium	Cofactor for >300 enzymes, ATP metabolism, DNA synthesis	Alcoholism, diarrhea, diuretics, DKA recovery, malabsorption	Neuromuscular irritability, tetany, tremor, seizures, refractory hypokalemia and hypocalcemia (magnesium required to release PTH and maintain K+)
Chromium	Insulin signaling (potentiates insulin)	Long-term TPN	Glucose intolerance, peripheral neuropathy

PART 3: MACRONUTRIENT DISORDERS

Protein-Energy Malnutrition

Feature	Kwashiorkor	Marasmus
Cause	Protein deficiency with adequate calories	Caloric (energy) deficiency overall
Edema	YES (pitting edema, ascites) - hypoalbuminemia	NO
Appearance	"Sugar baby" - chubby face, distended abdomen, flaky skin, hair changes	Severely wasted, cachexic, "old man" appearance
Albumin	Very low	Low (but less severe)
Hair	Discolored (flag sign - alternating bands), easily plucked	Thin, sparse
Where seen	Sudden dietary protein deficiency (e.g., weaning from breast milk to starchy diet)	Prolonged starvation, chronic illness, malignancy
Hepatomegaly	YES (fatty liver from impaired lipoprotein synthesis)	NO

Refeeding Syndrome

Definition: Life-threatening metabolic complication when nutrition is reintroduced too aggressively after prolonged starvation or malnutrition

At-risk patients:

Anorexia nervosa
Prolonged NPO/fasting (>5-7 days)
Chronic alcoholism
Cancer patients on prolonged chemo
Post-bariatric surgery
Kwashiorkor/marasmus

Mechanism: During starvation, cells are depleted of intracellular electrolytes. When carbohydrates are reintroduced → insulin surge → phosphate, potassium, and magnesium shift FROM blood INTO cells to support anabolism → severe electrolyte depletion

Hallmark electrolyte abnormality: Hypophosphatemia (most dangerous)

Consequences of hypophosphatemia:

Impaired ATP synthesis → muscle weakness, respiratory failure (can't wean from vent)
Hemolytic anemia
Cardiac arrhythmias and cardiac failure
Seizures, encephalopathy
Rhabdomyolysis

Other electrolyte abnormalities: Hypokalemia, hypomagnesemia, hyperglycemia, fluid overload

Prevention and management:

Identify high-risk patients BEFORE refeeding
Correct electrolytes (phosphate, K+, Mg2+) BEFORE starting nutrition
Start at LOW caloric rate (10-20 kcal/kg/day; some use 50% of estimated needs initially)
Slow and gradual increase over 4-7 days
Daily electrolyte monitoring (especially phosphate) during refeeding
Thiamine supplementation before and during refeeding
Target phosphate >1.0 mmol/L at all times

PART 4: ENTERAL VS. PARENTERAL NUTRITION

General Principle: "If the gut works, use it"

Enteral nutrition (tube feeding) is ALWAYS preferred over parenteral when the gut is functional:

Maintains gut mucosal integrity (prevents bacterial translocation)
Lower cost
Lower infection risk
Preserves gut immune function
Reduces stress ulcers

Enteral Nutrition (EN / Tube Feeding)

Indications: Patient cannot eat but has functional GI tract (e.g., stroke with dysphagia, intubated patients, head/neck cancer, neurological disorders)

Routes:

Nasogastric (NG): Short-term (<4 weeks), gastric emptying intact
Nasojejunal (NJ): High aspiration risk, gastroparesis, post-op
Percutaneous endoscopic gastrostomy (PEG): Long-term (>4 weeks)
Jejunostomy tube (J-tube): Post-operative, pancreatitis, gastroparesis

When to use jejunal feeding (not gastric):

Gastroparesis
High aspiration risk
Pancreatitis (jejunal bypasses pancreatic stimulation)
Post-op after gastric/esophageal surgery

Contraindications to EN:

Bowel obstruction
Severe ileus
Bowel ischemia
High-output enteric fistula

Total Parenteral Nutrition (TPN)

Indications:

Bowel obstruction (mechanical)
Short bowel syndrome (insufficient absorptive surface)
Severe inflammatory bowel disease with failed EN
High-output fistula
Severe malabsorption
Prolonged ileus
Inability to place enteral access

Access: Central venous catheter (CVC) required for TPN (high osmolarity - peripheral TPN only for <7-10 days at lower concentration)

TPN components:

Dextrose (carbohydrate): 3.4 kcal/g; typical 150-350g/day
Amino acids (protein): 4 kcal/g; typical 1-1.5 g/kg/day (higher in critically ill: 1.5-2 g/kg/day)
Lipid emulsion (fat): 9 kcal/g; 20-30% of calories
Electrolytes: Na, K, Ca, Mg, Phosphate, Acetate, Chloride
Vitamins: all water and fat soluble
Trace elements: Zn, Cu, Mn, Cr, Se
Insulin: add to TPN if glucose >180 mg/dL

TPN complications - know all of these:

Complication	Details
Hyperglycemia	Most common; glucose >180 mg/dL → add insulin; target 140-180 in ICU
Hypoglycemia	If TPN stopped abruptly → taper or give D10W
Hypertriglyceridemia	From lipid emulsion; hold lipids if TG >400
Refeeding syndrome	As described above - hypophosphatemia
Line sepsis / CLABSI	Catheter-associated bloodstream infection; Candida and Staph most common; change line, treat fungemia
Liver disease	Steatosis → cholestasis → cirrhosis with long-term TPN; elevated ALP, bilirubin; cycle TPN (12h on, 12h off) helps
Metabolic bone disease	Osteoporosis from long-term TPN
Electrolyte imbalances	Hypo/hyperkalemia, hypo/hypernatremia, hypophosphatemia
Acalculous cholecystitis	No enteral stimulation → bile stasis → gallbladder inflammation
Air embolism	During CVC insertion
Pneumothorax	CVC insertion complication
Thrombosis	CVC-related; anticoagulation may be needed

PART 5: SPECIAL NUTRITIONAL SITUATIONS (HIGH-YIELD FOR STEP 3)

Pregnancy Nutrition

Nutrient	Dose	Why
Folic acid	400-800 mcg/day preconception; 4 mg/day if prior NTD	Prevents neural tube defects
Iron	27 mg/day (vs. 18 mg in non-pregnant)	Expanded blood volume, fetal needs
Calcium	1000 mg/day	Fetal bone development; prevents maternal osteoporosis
Iodine	220 mcg/day	Fetal thyroid development; deficiency → cretinism
Vitamin D	600 IU/day	Calcium absorption, fetal bone
DHA (omega-3)	200-300 mg/day	Fetal brain and retinal development
Vitamin A	Do NOT exceed 10,000 IU/day	Teratogenic at high doses

Alcoholism - Nutritional Deficiencies to Know

Deficiency	Syndrome
Thiamine (B1)	Wernicke encephalopathy, Korsakoff syndrome, wet/dry beriberi
Folate	Megaloblastic anemia
Pyridoxine (B6)	Neuropathy, sideroblastic anemia
Niacin (B3)	Pellagra
Magnesium	Refractory hypokalemia, seizures (alcoholic withdrawal)
Zinc	Poor wound healing, impaired immunity, dysgeusia
Vitamin C	Scurvy
Vitamin D	Osteomalacia
Vitamin K	Coagulopathy (combined with liver disease)

Step 3 pearl: In any alcoholic admitted to the hospital - give thiamine 100 mg IV before ANY glucose. Glucose without thiamine → Wernicke encephalopathy (glucose depletes remaining thiamine stores).

Post-Bariatric Surgery Deficiencies

Gastric bypass and sleeve gastrectomy alter absorption and reduce intrinsic factor production:

Deficiency	Timing	Reason
Iron	Within months	Bypasses duodenum (main iron absorption site); low gastric acid
B12	1-2 years	Reduced IF from smaller stomach; bypassed stomach
Folate	Months	Reduced absorption
Calcium/Vitamin D	Months-years	Bypasses duodenum; fat malabsorption
Thiamine (B1)	Weeks-months	Reduced intake + absorption; protracted vomiting
Zinc	Months	Reduced absorption
Copper	Years	Reduced absorption

Post-bariatric supplementation (all patients): Multivitamin with iron + calcium citrate (NOT carbonate - requires acid) + vitamin D + B12 + B1 + folate

Inflammatory Bowel Disease - Nutritional Concerns

Crohn's (terminal ileum involvement): B12 deficiency (ileum is sole absorption site), fat malabsorption → fat-soluble vitamins (A, D, E, K)
Both IBD types: Iron deficiency anemia (blood loss), zinc deficiency, protein-energy malnutrition
Sulfasalazine: Folate antagonist - supplement folate

Malabsorption Syndromes - Nutritional Consequences

Celiac disease (proximal small bowel): Iron, folate, calcium, fat-soluble vitamins

Short bowel syndrome: Depends on which segment is lost:

Jejunum loss: most absorption still intact (ileum compensates)
Terminal ileum loss: B12 (irreversible), bile salts (→ fat malabsorption, fat-soluble vitamin deficiency), oxalate hyperabsorption (→ calcium oxalate kidney stones)

PART 6: RAPID-REVIEW DEFICIENCY TABLE (Step 3 Board Format)

Nutrient	Classic Presentation	Key Associations
Vitamin A	Night blindness → Bitot's spots → xerophthalmia	Fat malabsorption, measles
Vitamin D	Rickets (kids), osteomalacia (adults)	No sun, CKD, fat malabsorption
Vitamin E	Spinocerebellar ataxia + peripheral neuropathy	Abetalipoproteinemia, fat malabsorption
Vitamin K	Elevated PT, bleeding, ecchymoses	Newborns, antibiotics, fat malabsorption
B1 (Thiamine)	Wernicke triad (confusion + ophthalmoplegia + ataxia), beriberi	Alcoholism, give before glucose
B2 (Riboflavin)	Cheilosis, magenta tongue, corneal vascularization	Alcoholism
B3 (Niacin)	Pellagra: dermatitis + diarrhea + dementia	Alcoholism, INH, carcinoid, Hartnup
B6 (Pyridoxine)	Neuropathy, sideroblastic anemia, seizures (infants)	INH therapy - always give B6 with INH
B9 (Folate)	Megaloblastic anemia, elevated homocysteine, NO neuro	Alcoholism, MTX, pregnancy
B12 (Cobalamin)	Megaloblastic anemia + subacute combined degeneration	Pernicious anemia, veganism, terminal ileum disease, metformin
Vitamin C	Scurvy: perifollicular petechiae, corkscrew hairs, bleeding gums	Alcoholism, elderly, smokers
Iron	Microcytic hypochromic anemia, koilonychia, pica, Plummer-Vinson	Chronic blood loss, pregnancy, celiac
Zinc	Acrodermatitis enteropathica, poor wound healing, alopecia, anosmia	TPN, Crohn's, alcoholism
Iodine	Goiter, hypothyroidism, cretinism	Endemic in mountainous regions
Selenium	Keshan disease (cardiomyopathy)	TPN, China
Magnesium	Refractory hypokalemia and hypocalcemia, seizures, tetany	Alcoholism, diarrhea, diuretics
Copper	Microcytic anemia (sideroblastic), neuropathy, resembles scurvy	TPN, excess zinc

PART 7: CLINICAL NUTRITION CALCULATIONS (Step 3)

Daily caloric needs:

Average adult: 25-30 kcal/kg/day
Critically ill/ICU: 25-30 kcal/kg/day (avoid overfeeding)
Obese patients: use adjusted body weight

Protein requirements:

Normal adults: 0.8 g/kg/day
Hospitalized patients: 1.0-1.5 g/kg/day
Critically ill (ICU): 1.5-2.0 g/kg/day
Burns, severe trauma: up to 2.5 g/kg/day
CKD (non-dialysis): 0.6-0.8 g/kg/day (restrict protein)
CKD on dialysis: 1.2-1.5 g/kg/day (dialysis removes protein waste)

Caloric densities:

Carbohydrate: 4 kcal/g
Protein: 4 kcal/g
Fat: 9 kcal/g
Alcohol: 7 kcal/g

Nitrogen balance = Protein in (g/day)/6.25 - (urinary urea nitrogen + 4)

Positive = anabolic (building); Negative = catabolic (breaking down)

Sources: Harrison's Principles of Internal Medicine 22e, Robbins & Cotran Pathologic Basis of Disease, Andrews' Diseases of the Skin, Biochemistry (Lippincott), Goldman-Cecil Medicine, Adams & Victor's Neurology, Current Surgical Therapy.

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