Step 3 Question - How to answer

[Paperboydoc]

Hey guys, I am a little confused on how to answer a question when asked "What is the most appropriate step for diagnosis" or "What is the best next step for diagnosis"

First are these two asking different questions?

And second do they want us to answer THE GOLD Standard or just the next best possible way to diagnose the case.

For example : 1. Patient with TIA symptoms - would you chose US Carotids or CT Angio?

2. Or you suspect osteo - do we choose MRI or biopsy? If they ask most appropiate step for diagnosis.

Thank You

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[igcgnerd]

They are both asking for the best initial test IMO. That's what the second question is most certainly asking.

Example one: ct of head w/o contrast.
Example 2: ESR or crp

 

[Paperboydoc]

Interesting....but then why would they ask the question....what would be the next initial step? They ask for the initial step often and they also ask "what is the most appropriate for diagnosis.

 

[Paperboydoc]

Any other input from someone else, please?

Another example....Patient with PVD and they ask "what is the next best step in diagnosis"

Would you choose ABI or CTA? ABI would be the next best step but CTA would be the next best step in diagnosis, correct?

Im still confused on how to answer this question. Any help would be appreciated.

Thank You

 

[drake19]

Any other input from someone else, please?

Another example....Patient with PVD and they ask "what is the next best step in diagnosis"

Would you choose ABI or CTA? ABI would be the next best step but CTA would be the next best step in diagnosis, correct?

Im still confused on how to answer this question. Any help would be appreciated.

Thank You

-So when I answer questions I try to envision myself there with the patient and what I would do next.

-So with your example of PVD - the question-stem probably won't tell you its PVD - they'll give you clues like claudication symptoms, atherosclerotic risk factors, etc. so your first initial test in the office would be ABI and also other labs/tests to R/O other dx - ACS, spinal stenosis, etc.
-ABI is non-invasive, quick, done in office
-if ABI abnormal then maybe that will lead you to CTA
-plus you don't do a CTA immediately - since its invasive - you would do heavy risk factor modification first then consider CTA if patient is high risk or doesn't improve with conservative therapy

-now if they asked you what the most accurate test / or which test will give you definitive dx then it would be CTA and not ABI.

-this is why clinical skills and interacting with patients rather then just reading from a textbook is so important - build up your clinical intuition.

-also you have a differential with claudication - it could be spinal stenosis, etc.

-my point is just think about what you would do in that scenario - if everyone comes in with claudication would you go straight to CTA? (invasive procedure, contrast nephropathy risk , radiation, etc.)

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another example
someone comes in with chest pain - so do you go straight to CABG / coronary angiography?
-no you have EKG, cardiac enzymes, consult, aspirin, etc. before the above steps
-coronary angiography/PCI is usually the end point (definitive treatment) but it wouldn't be the best initial step if you don't even have EKG/enzymes yet