Step 2 CS workup

[JP2740]

Lets say that a patient has sore throat and you come up with your top 3 diff and it doesn't have pharyngitis in it. Would you exclude throat swab from your workup because strep isn't in the top 3 diff?

---

Members don't see this ad.

 

[Kaputt]

I wouldn't put anything in your workup unless it relates to your differential diagnosis. That's just my opinion though, don't take it as gospel. CS is not only testing safe patient care, but also reasonable patient care. Don't shotgun a billion unrelated tests on the exam just to cover your butt. This is pure speculation, but I imagine they would prefer you didn't order unnecessary tests (a throat swab would be unnecessary if strep isn't in your differential). Not sure if they'd actually remove points though.

But why wouldn't pharyngitis be in your differential in a patient with a sore throat? Common things being common, after all...

 

[evilbooyaa]

I don't think pharyngitis should ever not be in your DDx for any sort of sore throat, even if there is no fever or other URI sx.

What's a presentation/vignette that would cause you not to put pharyngitis in your DDx for sore throat? Now I'm curious as to how much other stuff I'm missing that could cause sore throat.

 

[Keona]

trauma to the oropharynx. can lead to a sore throat, and I think people would find you rather silly if you strep swabbed them

 

[Kaputt]

trauma to the oropharynx. can lead to a sore throat, and I think people would find you rather silly if you strep swabbed them

ok gotcha if there's a knife sticking out of the patient's throat, yeah, it's not strep throat

 

[Psai]

trauma to the oropharynx. can lead to a sore throat, and I think people would find you rather silly if you strep swabbed them

maybe they had some pyogenes on their neck as part of the flora and the knife put them on the fast track to the promised land
better safe than sorry i say

 

[JP2740]

I don't think pharyngitis should ever not be in your DDx for any sort of sore throat, even if there is no fever or other URI sx.

What's a presentation/vignette that would cause you not to put pharyngitis in your DDx for sore throat? Now I'm curious as to how much other stuff I'm missing that could cause sore throat.

I was thinking of a quick example. On first aid there was 1 case where it wasn't in their top 3. I know that it usualy should be in your diff

 

[Kaputt]

I was thinking of a quick example. On first aid there was 1 case where it wasn't in their top 3. I know that it usualy should be in your diff

Out of curiosity, what were the other things in the differential?

Also, they lowered the max number of DDx items from 5 to 3 since the most recent FA edition. So for every chief complaint like this I'd always reserve one spot for the very common, simple answer (like sore throat --> strep, cough --> URI, nausea/vomiting --> gastroenteritis, etc).

 

[JP2740]

26 yo M presents with sore throat, fever, rash, weight loss. History of IV drug abuse and sharing needles.

DDx: HIV acute, mono, hepatitis, viral pharyngitis, strep tonsilittis/scarlet fever, secondary syphilis.

Workup: CBC, smear, hiv Ab and viral load, cd4 count, monospot test, throat culture, vdrl/rpr, ast/alt/bili/alk P

 

[evilbooyaa]

Interesting. I guess the rash and weight loss are more concerning than the sore throat (+ the IVDA history). That being said, a scarlet fever rash secondary to pharyngitis (which if chronic could cause weight loss) would be higher (and thus more likely) on my differential than mono (unless there's fatigue/malaise/aches). I've never heard of mono causing weight loss.

 

[link2swim06]

I wouldn't put anything in your workup unless it relates to your differential diagnosis. That's just my opinion though, don't take it as gospel. CS is not only testing safe patient care, but also reasonable patient care. Don't shotgun a billion unrelated tests on the exam just to cover your butt. This is pure speculation, but I imagine they would prefer you didn't order unnecessary tests (a throat swab would be unnecessary if strep isn't in your differential). Not sure if they'd actually remove points though.

But why wouldn't pharyngitis be in your differential in a patient with a sore throat? Common things being common, after all...

I don't know if changed from last year. But I followed first aid's example and literally put every test possible that was related. I passed with a decent margin in ICE.

My understanding was you only got points for having the tests they wanted and didn't lose points for extra tests (this was my assumption).

I don't think CS's focus is on tests or treatment. I think it is literally to see if you can take a h&p and come up with a reasonable differential diagnosis.

 

[jm192]

I don't think they would punish you for having Pharyngitis in your top 3 in that scenario.

People with sore throats don't eat or drink, weight goes down. Obviously the history of IV drug abuse is concerning for other issues. But IV drug users get pharyngitis too.

To be fair, everything on step is given for a reason. Still, it's good medicine to rule out the strep throat.

 

[Kaputt]

I don't know if changed from last year. But I followed first aid's example and literally put every test possible that was related. I passed with a decent margin in ICE.

My understanding was you only got points for having the tests they wanted and didn't lose points for extra tests (this was my assumption).

I don't think CS's focus is on tests or treatment. I think it is literally to see if you can take a h&p and come up with a reasonable differential diagnosis.

Yeah I agree. There is, however, a limit to the # of tests you can order (I don't remember what it was but I hit it on one case). So def start with the good stuff first then shotgun it if you want to on your extra slots.