CS: differentials, workup, and counseling?

[kdburton]

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I'm taking CS on Monday and have a few questions. I just got done reading over all the mini-cases in FA and for the most part there is usually a pretty straight-forward top differential diagnosis but then the rest of the list (usually 5+ total) may be something that would be relatively unlikely given the information provided. Did most of you just list 5 things to fill up the DDx boxes even if some of the differentials were something you have a very low suspicion of the patient actually having given their H&P?

And similarly the workups they provide in FA are very extensive and redundant.. Is it best to put down as many tests as possible to confirm your top differential or to cast your net wide and put down the most important 1-2 tests for each of your top differentials? And how detailed do these need to be? Some parts of FA just say "LP" for example where others will say as one item "LP for culture, gram stain, PCR, cell count, yadda yadda."

Finally, what is expected in terms of "counseling"? I understand that if people smoke and its likely contributing to their presenting complaint that you can mention during your closure of the interview something along the lines of "Sir your smoking is probably causing you to have these asthma exacerbations, so it is best that you cut back or quit. I can provide you with options to help with that if you're interested." Are we supposed to address things that are unrelated to their chief complaint though? Time is obviously of the essence on this exam so if someone is coming in for a sports injury (that is clearly not septic arthritis) and they have multiple sexual partners are we still supposed to sit down and talk about the risks of their sexual activity in our "counseling"?

 

[mumd2011]

I didn't list 5 diagnoses on every patient. I only listed things that made sense, I didn't cast a super huge net in order to fill up the 5 spots. I am pretty sure that on most of my cases I did list 5 tests to order (but, remember that these add up fast even without reaching too far). Just your basic orders for a patient that would come to the ER can lead you to 5 diagnostic tests.

As far as counseling goes, I have been told (and, I did it) that you do need to address issues even if they don't seem relevant to the case. With smoking, at the very least you need to ask them if they are interested in quitting. If they say they are, it might be wise to go ahead and include in your summary to the patient that during the next visit you will discuss smoking cessation with them. If they aren't interested, you may want to say that smoking does have a significant impact on their health and that you encourage them to consider quitting. With alcohol, you may want to do the CAGE questionnaire. With unsafe sex practices, you may want to let them know that unsafe sex puts them at risk for many diseases and that you encourage the use of condoms, etc.

It seems crazy that you would eat up time from those precious few minutes to do the counseling stuff but I have heard that it does have an impact on your score. Plus, remembering to ask those questions in the social history could possibly give you insight into the differential diagnosis.

I passed the exam and took it in Philly. I will say that I almost never got finished with a patient before time was up because doing all that stuff takes some time. Just practice and make those counseling questions/responses part of your routine! Good luck!

 

[jtlc2345]

The other thing I would say about First Aid is that while their cases are very reflective of the exam, none of the actual cases I had in the exam had as much past medical and social history as in First Aid, thereby your actual history taking will be a bit shorter and you will have time for some rudimentary counseling.

Jonathan

 

[mumd2011]

The other thing I would say about First Aid is that while their cases are very reflective of the exam, none of the actual cases I had in the exam had as much past medical and social history as in First Aid, thereby your actual history taking will be a bit shorter and you will have time for some rudimentary counseling.

Jonathan

I would agree with this post. If you can master the FA cases (while timing yourself) you will be fine and have adequate time. This test is all about practice.

 

[Cliff Huxtable]

If you ask open ended questions like "anything else, or tell me more. . " will the SP's respond? Or do you have to ask specific questions like any chest pain, any SOB, any wheezing, etc. ?