Archer USMLE Step 3 CCS Workshop – 2012 Updated Sample Slides
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Solving Case 94
ALL in a 5 yr old boy
this was a 5 yr. old boy who came with weakness, disinterest in activity and lesion on leg. On examination, the lesion was ecchymosis and there was generalized lymphadenopathy with liver enlargement. ( CBC, BMP, LFTs, LDH — > revealed CBC : anemia, thrombocytopenia, neutropenia, lymphocytosis with 95% lymphocytes on DC, peripheral smear shows blasts ( schistocytes if there is concomitant DIC), LDH elevated in leukemias/ lymphomas, hepatosplenomegaly on ultrasound, CXR : many enlarged lymph nodes, then now need to do bone marrow biopsy ( diagnostic step) and this reveals many lymphoblasts, Admit and call ped/onc, ct chest and abdomen ( shows wide spread lymphadenopathy), bone scan, karyotype- counsel: cancer diagnosis. Check PT/PTT, FDPs and Fibrinogen to r/o DIC as 10% ALL patients may have DIC. If there is fever at presentation, make sure to get pan cultures. Make sure to order “neutropenia precautions” if there is absolute neutropenia ( ANC < 500)
Solving Case 92
20 month old boy/ Iron Deficiency Anemia
20 month old african american boy brought for fatigue and lethargy to office (initial orders – CBC reveals anemia, MICROCYTIC TYPE – do iron studies ( serum iron, ferritin and TIBC), blood lead levels, reticulocyte count, LFTs, haptoglobin, sickle screen and LDH – ferritin low. No evidence of hemolysis ( r/o sickle cell at this time), do stool guaic ( rectal exam in the beginning itself r/o blood loss as a cause of fe def ) –> Fe defeciency diagnosed which is most common in children during growth spurts if nutrition is not adequate ( remember you already ruled out other causes of Fe deficiency i.e; lead poisoning, GI blood loss, ongoing hemolysis) . Order iron rich diet ( very important to order this diet since lack of balanced diet is the reason for Fe def in children during growth spurts) , iron oral pills ( FERROUS SULFATE)- check cbc in 1 month/ schedule follow up visit – usually blood counts return to normal in 2 months –> so, schedule follow up CBC and Ferritin level for “LATER” date i.e; 2 months later on 5 minute screen ( continue ferrous sulfate for at least 6 months even when blood count normalized)
Solving Case 91.
Dehydration/ Hypernatremia in an Elderly man
70 y/o man with altered mental status, no urine output sent from NH to ER . No fever. ( BMP comes back shows NA + 160, BUN high, Crea normal) –> two things here , this patient has confusion which could be secondary to dehydration or hypernatremia. If euvolemic hypernatremia with CNS symptoms –> you would use D5W IV , However, in this case there is a clue that the urine output is low –> indicating hypovolemic hypernatremia –> so, would hydrate first with NS , NG tube, free water orally, R/o sepsis ( if cbc showed leucocytosis or if there is fever – please be sure to r/o sepsis , get cxr, blood cx, urinalysis and urine cx, if any source of infection seen start emperical antibiotics pending cultures), get head CT, foley catheter ( r/o obstructive uropathy since there is no urine output), and next put orders to monitor pts response to your therapy ( I/O monitoring, neurochecks q4hrs and BMP q4hrs – check if Na and BUN are improving, dont drop Na too fast due to risk of cerebral edema)
Dear sir,
How are you? I enjoyed your CCS session last sunday. I have one queston for you.I was doing CCS cases in USMLEWORLD software.
In one case pt came with HTN of 230/140,severe headache,nausea,vominting. I gave him
Nitroprusside IV one bolus
metoprolol IV continuous
phenergan iv one time
Morphine Iv one time.
In the expanation USMLE world gave for this case,
they managed with Nitroprusside alone.(Arerial Line).no other medications. In USmle world explantion, they gave Nitroprusside via arterial line after getting head ct,ecg,bmp results.
Head CT negative for Hemorrhage
Ecg showed LVH
BMP–mild elevated BUN and Creatinine
UA—-mild proteinuria.
After getting the above results adminitered Iv nitroprusside continuously .
Here my question is
Can we address their Head ache,nausea,vomiting?
Do We have to treat him only with nitroprusside?
If we can give the four medications i described above,we have to give them before physical examination or after physical examination.
Could you please have a look at this and let me know management clearly.
Thanks in advance ,
praveena.
.
You did well.
Here the symptoms – headache, vomiting are due to raised intracranial tension from Hypertensive encephalopathy. So, they should improve on rxng the blood pressure alone. However, you can use symptomatic therapy like tylenol and reglan or zoffran. Phenergan may cause sedation – so stay away in this case.
Sodium nitroprusside is not given via. arterial line. You probably interpreted it wrong. Arterial line in this case is used to monitor the blood pressure closely and accurately so as to get an accurate reading on Mean arterial pressure (MAP). As you monitor the BP via, arterial line, we can adjust the rate of IV nitroprusside so as to achieve the goal MAP ( make sure not to drop it too fast either). Monitor with A line and order continuous BP monitor along with check, blood pressure every 1hr. Order neurochecks every 2 hrs. HEENT exam on physical to check the eyes and possible papilledema
Hypertensive encephalopathy begins slowly with onset of headache, nausea and vomiting and then, non focal neuro deficits. In the case above ( note that they gave blood pressure >220/120, which is a cut off BP to start antihypertensive therapy even in a ischemic stroke), if the history or focused physical is not suggestive of ischemic stroke (i.e; no focal neurological deficits) , one should not wait until the CT head is completed to start an antihypertensive agent. CT must be done to rule out cerebral hemorrhage but one should not wait until CT comes back. If you are trying to rule out ischemic stroke based on the CT alone realize that it might not even appear on the CT for first 24 hours. As such, MRI is the best choice to differentiate hypertensive encephalopathy from ischemic stroke but MRI is even more time consuming.
So go by your clinical exam and history. Because neurologic symptoms ( non localizing neuro deficits like restlessness, confusion, seizures and coma) in hypertensive encephalopathy differ from the sudden onset of focal neurologic symptoms typically seen with a stroke or hemorrhage. Do order a CT scan of head, BMP, Cardiac enzymes ( to rule out other target organ effects like renal failure and myocardial infarction) , CXR, EKG, 2D ECHO, and also start antihypertensive agent on the first screen itself when bp is greater than 220/120. It seems like in the scenario you mentioned, they have waited at least 30 minutes ( CT scan takes 30 mins in ER on the CCS software) which is a delay in managing the above patient.
If BP is less than 220/120, obtain CT and wait for the CT results to r/o ischemic stroke/ hemorrhage and match with compatible physical exam findings to conclude that it is hypertensive encephalopathy. If no evidence of ischemic stroke, start nitroprusside
Nitroprusside is usually the drug of choice especially when SBP > 220. Other drugs that can be used are labetalol, nicardipine and fenoldapam
Now, as you run the drip and monitor BP , the case might end. Sometimes, the case may take you to the next day and farther. Once, patient is clinically better, start oral medications and taper off nitroprusside ( on CCS, monitor BP after starting oral meds and then stop the nitro drip).
If case ended and you are on 5-minute screen – think what could have caused her HYpertensive emergency? Follow up care, later tests and further work up are important on 5 min screen.
Most important cause of hypertensive urgency/ emergency is non compliance with medications. However, Work up for secondary hypertension is important in the patients presenting with emergencies like this – i.e; especially if these patients were compliant or if there are any clues to suggest a secondary cause in the history ( episodic headache, palpitations, episodic and labile bp) or physical ( abdominal bruit) or on the labs ( hypokalemia). Order MRA of the renal artery, Calcium level, TSH, plasma metanephrines and obtain PAC/ PRA ratio. Discontinue NSAIDS if the patient is using them for some reason.
another thing – do not give metoprolol yet because you are already starting nitroprusside via IV drip. ONce patient stable, you can start approprial oral medicine ( metoprolol, ACEI or calcium channel blocker/ HCTZ)
Dear Dr. Red,
My question is related with nephrotic syndrome CCS case.
How do we know when to treat them as outpatient or inpatient?
Depends on their albumin levels?
I read the nefrotic syndrome case from USMLEWORD website (case 46) and now I am confused!
I will copy-paste that case so you can highlight the differences for me if you have time!
Thank you very much,
Paula Stasencu
46)
CASE Location: Outpatient clinic
Vitals: Temperature of 36.3C; H.R: 95/min; R.R: 22/min; Blood pressure is 85/50
lying down and 77/46 mm Hg standing.
C.C: Swelling
HPI:
The patient is a three-year-old white male who presents with his mother for
evaluation of facial and scrotal swelling of ten days duration. Mother reports
that the child had been well until one day prior to admission when she noticed
the onset of swelling in his face. She also noted that he had scrotal swelling
because he is almost potty trained. She notes some decrease in his urine output
as well, although no change in color of the urine, other than becoming somewhat
more concentrated. He has had no preceding diarrheal illness, sore throat,
abdominal complaints, fevers, and rashes. Mother reports that the child has not
complained of any pain syndrome. He does seem to be a little bit more tired
than usual. Birth history is unremarkable. All of his immunizations are up to
date. SH: He lives with his parents; two older siblings who are healthy, and
have had no hospitalizations. There are no pets in the home. There are no
smokers in the home. Risk for tuberculosis is low. Development has been
normal.
How to approach this case?
Determine the nature and etiology of the “swelling”, including whether it’s
edema or something like hives. Examine the patient to decide whether he needs
inpatient or outpatient management.
Physical exam:
General appearance
HEENT/Neck
Heart
Lung
Abdomen
Genitourinary
Extremities
Skin
CNS
Results:
General: well-developed, well-nourished white male in no acute distress. HEENT:
remarkable for periorbital edema. Mucous membranes are slightly dry. Neck is
supple without lymphadenopathy or thyromegaly. Pupils normal. Cardiovascular:
Regular rate and rhythm without murmurs, rubs or gallops. Lungs: very faint
rales at the bases and otherwise clear. Abdomen is soft, nontender,
nondistended. There are normoactive bowel sounds. There is 1+ sacral edema. +
fluid wave. GU: There is scrotal edema present. There is no tenderness to
palpation and the cremasteric reflex is intact bilaterally. Extremities: Pulses
are 2/4 in the radial, femoral, and dorsalis pedis areas. Hands and feet show
2+ pitting edema and are otherwise unremarkable. Neurologic is nonfocal and
appropriate.
Discussion:
This is a three-year-old patient who is manifesting signs of generalized edema,
most prominent in his face hands and scrotum. The leading diagnosis in this age
frame for such marked edema is nephrotic syndrome secondary to minimal change
disease.
Order:
Urinalysis, stat
Basic metabolic panel, stat
CBC with differential, stat
LFTs
Lipid panel
PT/INR, PTT
Complement 3 and 4 levels
Results:
Urinalysis shows 4+ protein, no blood, no RBCs, specific gravity is 1.030,
CBC shows a white count of 7, hemoglobin 12.6, hematocrit 36, and platelets 240.
Complete metabolic panel (LFTs + BMP) reveals an albumin of 1.5, normal liver
function tests, sodium 130, potassium 4.0, chloride 96, bicarbonate 20, BUN 10,
creatinine 0.7, glucose 78, calcium 9.4, cholesterol level is 320 mg/dl. Serum
albumin is 1.5 gm/dl. Serum protein is 3.7. PT, PTT are normal. Complement
levels within normal. Patient has orthostatic hypotension and mild dehydration.
Order:
Admit to floor
Inputs/outputs
Vital signs q4; Continuous cardiorespiratory monitoring
Nephrology consult
Albumin 25% solution IV, 1 gr/kg body weight, infused over 8 hours
Lasix (Furosemide), 1 mg/kg, administered halfway through the albumin infusion
Complete metabolic panel q AM
No salt added, high protein diet.
Results:
Patient responds with good diuresis to albumin and lasix therapy over 24 hours.
Vital signs remain stable. Orthostasis resolves.
Electrolytes and renal function remain stable.
Order:
Prednisone 2 mg/kg per day, may give in divided dose, po
Vital signs q 12 hours
Repeat albumin and lasix therapy.
Results:
Patient tolerates prednisone.
Remains clinically stable.
Order review:
Discharge to home.
Prednisone for 4-6 weeks.
Follow up in 3-5 days.
Hey Paula,
All stable nephrotic syndrome (NS) cases are managed as outpatient.
An outpatient NS child can be treated with salt restriction and prednisone trial. Prednisone should be at least 4 weeks. If things dont improve, prednsone should be continued for another 4 weeks before going for renal biopsy.
Pneumococcal vaccine should be given to all NS children because they are at high risk of bacterial infection ( include it on your 5 min screen orders)
NS is a hypercoagulable condition secondary to loss of anti-thrombin III. But there is NO role for DVT prophylaxis with heparin or warfarin in NS. So, the only thing you need to do is ordering activity such as “ambulate” on CCS ( early mobilization)
INPATIENT:
Nephrotic syndrome patients should be admitted if they have :
a) Intravascular volume depletion ( presenting as orthostatic Hypotension or Shock)
b) Massive Pleural effusions/ Ascites ( presenting with SOB and rales on lung exam).
Once you admit, realize the reason why you are admitting.
If the reason is orthostasis/ hypotension – give albumin infusion as albumin mobilizes fluid from outside in to intravascular compartment. This may treat orthostasis. DO NOT USE DIURETICS YET UNLESS THE PATIENT IS COMPLETELY VOLUME STABILIZED. ( Unlike the way they did in UW where they claim that patient is orthostatic and dehydrated and they are also starting lasix even before orthostasis resolved – This is a wrong approach because they should first satbilize the volume. Giving aggressive diuresis in that patient who came with dehydration would cause further volume depletion and may precipitate acute renal failure. You may be penalized for it on the CCS)
If you admitted the patient for respiratory distress from pleural effusions, give both albumin+lasix to get rid of the fluid from thorax.
Aggressive diuresis with albumin and furosemide should be given in patients with anasarca who have respiratory distress due to massive ascites or pleural effusions or in cases of scrotal edema so severe that it may cause perforation.
To summarize your case,
The case I made you practice in the workshop did not have two things UW included in their case – “ORTHOSTATIC HYPOTENSION” and “DEHYDRATION” – If these are present, patient will need admisssion and albumin infusion ( ( here patient is orthostatic so, albumin is justified but diuretics are not justified unless the patient not orthostatic and also, has resp compromise)
Patient should also be admitted if he has respiratory distress from pleural effusions/ severe ascites from very low albumin.
Hope this helps
Hello Doctor,
1. I did CCS case of HYPERTENSIVE EMERGENCY on USMLEWORLD . when i order ctscan , report time was after 4hrs. it was obvious from physical that he had organ damage like eye changes, raise bun/creat, bp was 230/180. no focal deficits pointing to stroke so i did not wait for 4 hrs and went ahead and gave him IV notropruside., but aassesment says we should start antihypertensive after comfirming no stroke from ctscan.
should i follow that protocol or am i right in giong ahead and giving him antihypertensive?
does ctscan take really this much long time in real life i don’tthink, but we should not let pt die in those 4 hrs waiting scan, i mean anything can happen with that high bp.?
2. please tell me how to differentiate bell’s palsy, stroke, lyme facial palsy?
1. First and foremost, CT scan takes only 30minutes to come back in the ER setting. If there are no focal neuro deficits, you can start nitroprusside with out waiting for CT however, in a comatose patient it is some times difficult to assess the neurological function. So, wait for Ct and then start nitroprusside. Waiting for 30 minutes for CT is not a big thing.
I guess if you are using USMLEWORLD software, as per some students, several test report time is wrong there as they did not adequately adjust the report times based on location and some one should write to them to correct those.
You can try putting CT head, stat on the original test software. The report time changes based on the location. The report time for a CT head stat is 30 minutes in the ER. The report time for CT Head stat is 4 hours in the office. Try it on case 1 and try it on case 2 on the test software and you can appreciate the difference.
Even if your patient came to the office, if you think you need a stat CT you should send the patient to ER and then order a stat CT
Q2) clinically, bells palsy involves the whole side of the face where as UMN facial nerve stroke involves lower part of the face unless it is a cortical (central) facial issue. If clinically you have a problem differentiating , CT head and MRI can help r/o stroke.
Clinically it is difficult to differentiate Late lymes from bells palsy. You need to suspect lyme based on endemicity as well as risk factors like previous tick exposure. If you suspect it, Get a lyme serology. IF serology -ve, rx as bells ( acyclovir+steroids). If serology +ve, use doxycycline
Hello Sir,
I had taken ur ccs workshop for nov 15
I had some doubts in the mgt of TRANSIENT ISCHEMIC ATTACKS
1) If carotid stenosis is detected in doppler ,then is it correct to go directly to surgery or should we do carotid angio before that.
what r the indications to do carotid angio?
2) What is the correct approach in management of ischemic and hemorragic stroke including BP control?
3) I will write the management of SAH
Please correct me .
CT SCAN head
Bed rest
head elevation
dulcolax
For sedation can we give morphine?
nimodipine
bp monitoring
ecg monitoring
frequent neurological exam
carotid angiography
sent neuro surgery consult if saccular aneurysm
npo,pt ptt blood grp
post for surgery
post op bp monitoring
patient stable
discharge on oral anti hypertensives
appropriate counsel
*cerebral angiography
*** I just wanted to thank you! I have not yet received my score, but I felt very confident with CCS portion. I only had time to practice a few cases a read over some explanations in UW the day before my CCS part of step 3. I do not recommend this, but I had practiced CCS in the past. But the KEY FACTOR was your CCS lecture. The day before day 1 of my step 3 i listened to half of your CCS lecture (which also helped me answering some MCQ’s) and then the other half when I got home after day 1. I cannot tell you how HELPFUL this was for me! I felt as if I was hearing you telling me what to do during the exam. Thank you…regardless of what my score is…thank you! ***
Ricardo
HI DOC,
I need your your diagnostic work up and treatment for case..54
Hi Dr RED
I had taken the ccs workshop 2 weeks back…I had a few doubts..
1. a case of perforated duodenal ulcer in the USMLEWORLD ccs software, they
want us to wait 12 grs before we take the patient to surgery… the
patient has rebound tenderness all over the abdomen…is it the right
approach or do we take the patient right away for laparotomy as it is
peritonitis…
2.i have tried a few cases like tia on USMLEWORLD ..where patient needed carotid
endarterectomy…and the peritonitis case… the surgeon is not
accepting the patient for surgery as you had demonstrated in the
workshop…where the surgeon accepts patient for surgery after the ct
scan result in aortic dissection …..so could it be that the software
is not designed in the way 2 accept for surgery …coz the moment u
type in the surgery name the case ends.
3.do we have to discontinue the oral meds of patients when we admit
for surgery..like hypertensive meds and diabetic oral meds…what is
the protocol for the meds patent already is using?
Thanks a lot
Huma
Dear Huma,
Q1. If you can recall, I remember telling you some fatal mistakes in UW software during the workshop.
This is one such fatal mistake in their algorithm writing and also not following the correct indication sfor Surgery. This should not lead you to think that surgery must be delayed. In the exam, if you find critical signs such as generalized rebound tenderness or rigidity, call surgical consult STAT and
surgery will accept that patient. Once surgeon accepts, order pre-op orders. If there is no rebound tenderness or rigidity, one may wait as some small perforations may seal up —> I mean to say if symptoms and signs of generalized peritonitis are absent, a conservative approach hence can be used but not when peritonitis is present.
Q2. Again, I mentioned this in the workshop. Please do not go with what UW said in those cases, these are errors. UW is a good source but you should know these serious errors in some cases. In your exam, if you call the surgeon and if you have met the criteria for sirgery –> Surgeon will accept. Once you get the acceptance, put the pre-op orders such as NPO, IVA, NSS, Type and crossmatch, obtain consent and Name of the procedure.
Q3. Once you place the patient on NPO, you may switch necessary medications to IV route
Good Luck
Red
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Dear Dr. Red
It was great to do workshop with you this Sunday. You mentioned that while patient is home waiting for next appointment and we get any abonormal labe like low hb. low hct then we can order iron studies at the same time. After doing so we reschedule appointment. In Usmle world I treid to do it but it did not allow me. Should I try on ecfmg five cases?
Sir, I can not thank you enough for what your course has done to me. I got my score today and passed with a dazzling 246/99. Words can not express my gratitude because everything you said worked for me. This is you victory and I hope you will continue to help many more ppl like me. I am looking for prematch and if you can give me any tips, I would greatly appreciate it.
Anjum asked, ” In Usmle world I treid to do it but it did not allow me. Should I try on ecfmg five cases?”
Yes Anjum.
That is a big drawback with USMLE World software. It is not an exact copy of USMLE CCS Software. Please practice those usmle world cases on USMLE CCS Software. If you train yourself on USMLE World in the above way, you can get in to problems on the exam with the office cases. If you put in orders on USMLE Original software, you can see that it allows you to order follow up labs even when your patient is at home. This is what we all do in clinical practice as well. A patient need not come to office time and again just for follow up lab work.
Dr. Red, thank you very much for good practice I got listening to your workshops. I think, it will greatly improve my score on Step 3. I have some questions and would like to ask your favor to answer. One of them is: what is your general approach in HIV case: something like office case of young pt with cough or diarrhea and no obvious h/o multiple sex partners. In my opinion, it would be a good one to practice. Also, peds case of piloric stenosis or intussiseption. The other question is that my hours of watching running out quicker than I expected. Is it something wrong in the way they calculated? Because I resently purchased it, and it’s already just a few left. I think, every time I watch part of the video, it still counts as a whole video. So, if would clarify, please. Next question, during workshops, you mention sometimes, question logs. Could you, please, explain what it is. Last 2 questions: what is the best e-mail to reach you, and how individual ccs tutoring works, price, hours, etc. Thank you!
With respect, Gennadiy.
Dear Dr Red,
Nice talking to you today. Thank you for pointing to your blog. It looks vey helpful and i have to keep coming back to join the discussion. Your help is appreciated.
Shoib
I attended your CCS workshop on 1/16/2011 which I found very useful. Thanks very much! I had a question about the IV normal saline that we order as a part of so many cases. What kind of NSS should it be – 0.9% or half-normal or other? Can I just assume to order 0.9% NSS for most cases without worrying about it too much? Or are there any indications which dictate this decision – for example, ordering half NSS as opposed to 0.9% when BMP shows hypernatremia/normal sodium?
Dear Adi,
Thank you for your feedback.
For all cases on hypotension, shock or dehydration i.e; the cases in which you already know that the patient is hypovolemic, it is important to use isotonic fluid such as 0.9% NS. Most other cases, where you start a temporary fluid before when you place a patient NPO, start 0.9% NS if you expect to start a diet with in next 24 hours.
For cases of DKA, start with 0.9% NS but once sugar falls below 250mg% , change to d51/2ns . For cases of hyponatremia and hypernatremia, you must balance the fluid choice. For example, for a patient with hypovolemic hypernatremia with out CNS manifestations, I would still use 0.9% NS where as for a patient with CNS manifestations and euvolemic hypernatremia, I would use 5% DEXTROSE IV ( This is like giving IV free water with No Na in it). For a patient with euvolemic hypernatremia with no symptoms, I would use free water orally. So, you need to apply the concept of IV fluid depending on the case you are dealing with. But for most other cases, just choose 0.9% NS.
I have explained all the fluid choices and electrolyte management in Nephrology/ Acid-Base lecture. If you need more information, please review it.
Wish you all the best.
Red
Thanks a bunch Dr Red, as usual!
I had another query pertaining to the differences between the management of NSTEMI and STEMI. Actually, there was some disturbance in the audio transmission at my end during that case due to which I did not get to hear to it in totality.
i) I know thrombolytics have no role in NSTEMI.
ii) What about heparin usage? I know that heparin is used routinely in NSTEMI. But we used heparin in STEMI too during the case practice that day?
iii) GIIb/IIIa are routinely indicated in NSTEMI while they are indicated only before/during angioplasty in STEMI. Right?
iv) Angioplasty is not the front runner in management of NSTEMI unlike STEMI. But what are the indications to its use in NSTEMI? One that I could hear was when chest pain fails to show remission. Others?
v) Any other differences?
Thanks,
Adi
Hello Dr. Red,
Can you please walk through the management of Cases 3, 4, 9, 20, 28, 31, 47, 48, 84, 88, 94, 97.
Thank you!
Jabeen
Dear Sir, could you please explain the approach for these cases
1. 17 yr old with depression
2. TB
3. Cellulitis
4. Pulmonary HTN
5. Atrophic vaginitis
6. Ovarian cyst
7. Post-op atelectasis
8. STEMI
9. Aortic aneurysm
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Hello Dr Red
Apart from surgery and minor procedure, when do you make a patient npo?
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