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Concerned about "what would you do next" questions

Discussion in 'Step II' started by 1nycdoc8, Aug 8, 2011.

  1. 1nycdoc8

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    Hey everyone, I have 3 weeks of studying time for the step 2 CK and I was wondering if you guys could help me with tips for answer those annoying "what would you do next" type q's. Specifically what resources you use. Thanks!
     
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  3. shantster

    shantster Eye protection!
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    This is my thought process with it:

    1) Is the patient stable? If not, stabilize. So if in severe respiratory distress, intubate. If hypotensive, fluids, etc.

    If stable, then start to think about the diagnosis

    2) Is the suspected diagnosis something that I need to start treating prior to studies because of complications? The big one that comes to mind here is GCA - always give steroids if suspected before the biopsy.

    3) If no to #2, then do studies based on suspected diagnosis or to rule out something horrible that could be causing the symptoms.

    At least that's a basic rubric to my thought process. Usually electrolytes fall into #2 so if there's something abnormal that makes them symptomatic (like elevated calcium), fix that before figuring out why they have it.
     
  4. FrickenhugeMD

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    In response to number 3 above, I have found that if you are going to do a diagnostic study in a stable patient you usually should go with the cheapest and most non-invasive test first. That's usually a pretty good rule of thumb, like if someone has abd. pain --> always pick the ultrasound before jumping into ordering a CT, chest pain get a EKG before other things, ect.

    It isnt always the case, but it will be more obvious when they are asking about the best or most sensitive/specific thing to do next, as opposed to just "next step"
     
  5. Xamwell

    Xamwell Englishologist
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    I agree with the above two posters and would add my little rule of thumb. Given any case presentation in the stem of the question followed by the phrase: "What's the next best step," my brain does the following.

    I look at the answer choices, be they diagnostic tests, x-rays, meds, etc. If, as said above, the patient is stable and needs no interventions (A,B,C's) then I consider which test has the most "bang for the buck" given the case. I'll try to cook up an example (it probably won't be perfect).

    An 78 y/o man presents to the ED from nursing home for confusion. He's oriented to place but not to person or time. He has difficulty concentrating to answer your questions, seeming to nod off intermittently. He feels weak. Vitals: HR: 110 RR: 20 BP: 136/80 Temp: 96.3 SpO2: 98% on RA. PmHx includes: CAD, HTN, DM, and BPH. He is able to respond to deny chest pain or shortness of breath. He has not had cough or headache. He denies surgeries. He is unsure of his medications and whether or not he took them today. What's the next best step in evaluation?

    A) CBC
    B) Chest CT
    C) D-Dimer
    D) BNP
    E ) Blood Cultures
    F ) Consult hospital ethics committee
    G) UA
    H) Urine Tox

    I suppose it's easy to breakdown an example once you've created it, but for the sake of argument, if this sort of question appeared here would be my approach. Taking the history into account I'm thinking infectious process. Looking at each order I wonder which is the most bang for the buck. In doing so I ask myself 1) what's a likely diagnosis and a test that will logically hone the field or give you a helpful result at all given the circumstances, 2) which test will change my management depending on its result, 3) are there easier/cheaper tests than others?

    If I order a CBC and it comes back normal, do I send this guy home or change what I was going to do? No. If it comes back with an elevated or depressed WBC count will it change anything? No. He's got enough infectious symptomatolology (sic) to support a treatment as is.

    Along those lines blood cultures aren't incorrect to order in a febrile patient, however if you order them "next" it doesn't help your management (unless there's a 3-day waiting period to buy guns and administer antibiotics) so it's not the NEXT best step.

    Chest CT may show a pneumonia, P.E. or pleural effusion, but it's expensive and not going to be a logical first step in an elderly, febrile patient. If you were to order the D-Dimer, it will not change your management. Say it comes back high. Does this guy more likely have a P.E. or an occult infection. One could argue that he is tachycardic and confused which "could" be a P.E., but of course in the face of numerous other symptoms o' infection this test, even if positive, will not have a good doctor pumping this guy full of heparin. Similarly the BNP is not a first step. It tries to hammer down the CHF diagnosis for which this guy has risk factors but no findings suggestive of.

    It's best to never involve the hospital ethics committee. While they debate, your patient dies. I can think of one practice question that actually set up a scenario such that the ethics committee was the right call. I think it was in COMBANK and I had to give them credit. It was epic. It probably won't happen on the real thing--certainly not on the USMLE.

    If I order a UA and it comes back positive for infection (frequent in the experienced, aged population) then it will change what I do. I'll have a probable answer. The stem will give you clues to hang your hat on. In this gentleman, his diabetes and BPH and nursing-home-ness predispose to complicated UTI. A simple, cheap urinalysis (esp w/ culture) goes a long way in this case.

    For sake of argument, place Fingerstick Blood Glucose in place of urinalysis and it becomes the best answer. A quick, cheap test that, if negative in an altered mental status patient w/ history of diabetes and poor med control, rules out a dangerous needs-to-be-treated diagnosis in 10 seconds.

    I hope all that was coherent and helpful. I am on my way to bed. Anyone can rephrase it more succinctly, I don't mind.

    :)
     
  6. OveractiveBrain

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    So, this is the entirety of Step 2 questions. Its called the hinge question. Let me explain how Step questions work, and let's see if it helps you answer the question. The post above mine was very thorough with examples, let me back up and give you a little theory.

    Step 2 is not about curveballs. The expectation is that you have learned the typical patterns and prevalence of disease. You can recognize clear cases, identify risk factors, and synthesize a number of symptoms into a syndrome or a common diagnosis. The Step question has about 5-6 lines to tell you only enough information for you to form a diagnosis. That is, if they don't say its there you can assume its not. If they say it's there, then its very important. If they specifically say something is not there that's even MORE important (they are using up precious space specifically to dissuade you from one diagnosis). From that, you get a diagnosis.

    Now the hinge. Once you have a working diagnosis, they will ask you (in general) either which diagnostic, which diagnosis, or they will ask you management, phrased as "what will you do next?" The cool thing is that usually you don't have to decide between diagnose and management (that's an advanced skill). Usually, it will be between a number of tests, or a number of treatments, or simply a number of diagnoses.

    So in general my strategy was this.
    1. Read the last line of the question
    2. Glance at the option choices... this orients you
    3. Read the question stem with the answers in mind. If the question asks you to choose between a number of thyroid tests, look for things pertinent to thyroid. Highlight things in the question stem that are relevant to your option choices.
    4. Apply whats on your screen against your memory banks. This is were memorization comes in
    ...a. it sounds like hashimoto's.... TSH --> T4 --> antibodies
    ...b. it sounds like multinodular goiter... TSH --> T4 --> RAIU
    ...c. it sounds like Grave's... TSH --> T4 --> RAIU
    ...d. it sounds like STORM... INTERVENE! Beta blockers, steroids, PTU!

    Finally, for that "advanced skill" of choosing between diagnostic and intervention the answer is usually obvious. Either they are totally stable and ready for a test, or they are sh!tting the bed and are in need of intervention. If you need that 270 on Step 2, well then, you need to know a lot more about pretest probability. Does a first time pleural effusion in a person with CHF require a CT? Tap? Diuresis? That's a little harder, and there are very few questions like that. Take for granted that there are residents who still dispute what to do next, looking into their pocket medicines or even journal articles to help them choose. Some one with a bit more knowledge may know the answer already but the answer isn't always so obvious. If its hard for a resident in real life, it certainly is too hard for a medical student test. But something has to separate the 270s from the 250s.
     
    #5 OveractiveBrain, Aug 9, 2011
    Last edited: Aug 9, 2011
  7. Perudoc

    Perudoc New Member
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    Thank you guys. Your comments were very helpful.
    I am slow reader. What can I do? any tricks?
     
  8. OveractiveBrain

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    Learn to read faster?
     
  9. OveractiveBrain

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    [YOUTUBE]http://www.youtube.com/watch?v=09nGEHTsqqI[/YOUTUBE] skip to 9:30

    Viking "Here, you'll need this"
    Antonio: "I cannot lift this"
    Viking: "Grow Stronger"
     
  10. Perudoc

    Perudoc New Member
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    Thanks OveractiveBrain :0)

    Should I read first the last line + the answer choices?? this is what I meant :)
     
  11. shantster

    shantster Eye protection!
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    That's what I do. I also use it to strikethrough the options that I know aren't correct so that when I get to the end of the question, I'm not distracted by random choices. For example, if the question asks "what's the most likely diagnosis?" and it's all things that cause headaches, as soon as I read that the person is a 31 year old, I know that the answer is definitely not GCA no matter what the rest of the prompt provides. If it's a "what test will likely give the diagnosis?" then I think through what each test is indicated for before reading the prompt to help me focus on what type of study I need to do.
     
  12. Xamwell

    Xamwell Englishologist
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    I'm a very slow reader. Very slow. Except when it comes to tests. As stated before skip the first line. Read the last line first and decide if you can answer the question without reading anything else. You'd be surprised how much time this can save. On a block of 46 questions there's usually one or two (sometimes more) that feature a gigantic paragraph with a final sentence that has nothing to do with it. Example.

    Blah blah blah blah 46 year old male. Blah blah blah. Blah blah. Blah blah 110 14 98.0 124/76. Blah. Blah blah blah. Blah blah blah. Blah blah blah. Blah blah blah. Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah Blah is diabetic. What is the most likely cause of mortality in a diabetic patient?

    Even if the preceding paragraph wasn't a wall of "blah's" and vital signs the last question is standalone answerable. It may change if they said "What is the most likely cause of mortality in THIS patient (even then it's still heart disease unless he has a gunshot to the head or something to that effect). No matter what, if you read the last sentence and answer this you've saved yourself 2-4 minutes of reading.

    Further, as said above, scan the answer choices. Are they labs, meds, diagnoses? That will put you in the right frame of mind when you do end up reading the rest of the question. You'll be reading for specific details and, therefore, reading faster. Remember, they're not trying to trick you. The stuff is fairly straightforward. If something's not mentioned it's not there. The most they'll try to bury subtle details is to tell you there's a 24 y/o with chest pain and a bloody nose with white powder caked on his nostrils who might not mention the cocaine he just did. Otherwise they're all there.

    Practice this on question banks. It comes with practice. I finished the USMLE and COMLEX with an average of 15 minutes of free time per block with these methods. Practice practice practice. It will become second nature but it takes confidence which comes with, yes, practice.
     
  13. ThePursuit

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    rotfl
     

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