Best next step in management questions in Step 1

[Daitong]

Hi,

I'm getting killed on these (for example, RUQ pain, is the next step US or X-ray, etc).

Does anyone have a resource or general rules to follow for these next steps in management type of questions?

Any advice would be greatly appreciated!

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[Phloston]

Hi,

I'm getting killed on these (for example, RUQ pain, is the next step US or X-ray, etc).

Does anyone have a resource or general rules to follow for these next steps in management type of questions?

Any advice would be greatly appreciated!

'Next best step in Mx' questions are certainly step 2 realm, but apparently some have crept onto the step 1 as you've pointed out.

There's no specific resource for these types of questions, as often times intuition and judgement picked up through rotations are the key to answering these, which is why step 2 is done in clinical years. For both steps, an important point would be to err on the side of picking the less invasive and costly test first, in most circumstances. There are exceptions but that's a general rule.

For instance in cubital and carpal tunnel syndromes, a splint is the next best step over any type of surgical decompression.

If a patient is unstable who's had surgery or trauma, repeat surgery, however, is the answer over CT (eg urgent laparotomy needed after abdo surg with likely internal dehiscence).

Abdo gunshot wounds always need laparotomy.

'Fluids' is generally the answer when it's listed in many questions. It's the C in DRSABCD.

That being said, A comes before B, which comes before C, in any situation, so watch out. Sounds obvious but they might try to trick you, eg someone is exsanguinating but answer is airway.

 

[Kazaki]

I'd say ultrasound but I think it depends more on the patient. If it's a middle aged woman, then you're thinking cholecystitis, so ultrasound. If it's a pro boxer, maybe a lacerated liver, so CT.

 

[Phloston]

Ultrasound is for gallbladder and stones, whether chole- or choledocho-. Also good for pyloric stenosis and intussusception in paeds. Abdo CT is for most other internal structures, including pancreas and liver. Abdo X-ray is generally useless unless you're looking for intestinal obstruction. And that's important. That was HY on step 2, and in real life I saw a resident get upbraided for ordering an abdo X-ray, only for the consultant to essentially teach the resident that it's used to look for gas in the bowel. If you're trying to visualize the biliary tree and ultrasound as the best initial test didn't cut it, MRCP is the answer if you just want an image. If you are needing to be therapeutic as well, eg to remove a stone, then ERCP is correct after ultrasound. For cholecystitis, which is almost always secondary to obstruction, if ultrasound is negative, the answer is HIDA scan for best next step. If you want a good pancreas image and the CT was negative, endoscopic ultrasound is the answer.

 

[Pholston]

Abdo X-ray is generally useless unless you're looking for intestinal obstruction.

Also useful (diagnostic) for intestinal perforation (gas under diaphragm/pneumoperitoneum) and for pneumatosis intestinalis.
Also useful to see calcification in many conditions e.g. chronic pancreatitis, porcelain gallbladder etc etc.
As you can see, it is still the first step in management for many conditions.
Advantage of an X ray is that it can be done at bedside, so if the patient is too sick to be moved then it is sometimes the only option short of taking the pt for a laparotomy.

To answer OP's question- US is the next step depending on the other answer choices.
You might want to look at MTB (Master the Broad) for Step 2 CK to get an insight into these type of questions.

 

[Phloston]

Also useful (diagnostic) for intestinal perforation (gas under diaphragm/pneumoperitoneum) and for pneumatosis intestinalis.
Also useful to see calcification in many conditions e.g. chronic pancreatitis, porcelain gallbladder etc etc.
As you can see, it is still the first step in management for many conditions.
Advantage of an X ray is that it can be done at bedside, so if the patient is too sick to be moved then it is sometimes the only option short of taking the pt for a laparotomy.

To answer OP's question- US is the next step depending on the other answer choices.
You might want to look at MTB (Master the Broad) for Step 2 CK to get an insight into these type of questions.

If you get any gallbladder question it's definitely ultrasound, not abdo x-ray. And for pancreas imaging it's CT. More that AXR could incidentally pick up those findings of calcification, as could any x-ray. You do an AXR when you're looking for bowel air. If you start putting abdo x-ray as a next best step it's a danger zone. And chest x-ray is typically used for looking for air under the diaphragm, even though abdo x-ray can pick it up.

 

[Pholston]

You do an AXR when you're looking for bowel air.

I may be splitting hairs but more precisely you do an AxR to look for air-fluid levels (small bowel) or dilated bowel (large bowel) since air is normally present in the bowel. Also useful to diagnose may conditions including but not limited to cholecysto-enteric fistula (choledochoduodenal fistula leading to Gallstone ileus or cholecystocolic fistula etc).
You do a lateral decubitus AxR to look for pneumoperitoneum in a patient too sick to sit up.

The point I was trying to make is that the AxR is not a "useless" investigation and can be the next best step depending on the given scenario.

 

[Phloston]

I may be splitting hairs but more precisely you do an AxR to look for air-fluid levels (small bowel) or dilated bowel (large bowel) since air is normally present in the bowel. Also useful to diagnose may conditions including but not limited to cholecysto-enteric fistula (choledochoduodenal fistula leading to Gallstone ileus or cholecystocolic fistula etc).
You do a lateral decubitus AxR to look for pneumoperitoneum in a patient too sick to sit up.

The point I was trying to make is that the AxR is not a "useless" investigation and can be the next best step depending on the given scenario.

And the point I was making is that on the USMLE abdo x-ray is almost always the wrong answer.

 

[Pholston]

And the point I was making is that on the USMLE abdo x-ray is almost always the wrong answer.

In that case we have to agree to disagree (as explained above) that there can be no absolutes on USMLE but it depends on the given scenario and blanket statements like yours can be dangerous.

 

[Phloston]

Stop trolling

 

[Pholston]

Stop trolling

Very mature response.
Just because I disagree with you and have the knowledge to prove it doesn't mean I am trolling.

definition of trolling:
make a deliberately offensive or provocative online posting with the aim of upsetting someone or eliciting an angry response from them.

 

[Jabbed]

Phloston vs Phloston

3.. 2.. 1.. FIGHT