Dx of choice and Tx of choice for diseases

[mossyfiber12]

What is the diagnostic modality of choice for diverticulitis, pancreatitis, gallstones. I think it's CT for the first two and USG for gallstones but please correct me if I am wrong.

Also, is there a thread or another site where it lists the common diseases and their diagnostic modality and treatment of choice.

My test is in a couple of days and I am looking for some good review material.

Thanks as always!

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[LouisianaDoctor]

What is the diagnostic modality of choice for diverticulitis, pancreatitis, gallstones. I think it's CT for the first two and USG for gallstones but please correct me if I am wrong.

Also, is there a thread or another site where it lists the common diseases and their diagnostic modality and treatment of choice.

My test is in a couple of days and I am looking for some good review material.

Thanks as always!

You are correct for those three diseases. I don't know of a website, sorry.

 

[turkeyjerky]

although HIDA scan is more accurate overall for cholecystitis. Also, CT probably isn't really necessary for uncomplicated pancreatitis.

 

[Captopril]

The problem with USMLE is, you can't reason things out like this and expect to be correct. As ******ed as it is, you pretty much gotta just memorize "pancreatitis = abd CT, gallstones = abd USG" etc.

although HIDA scan is more accurate overall for cholecystitis. Also, CT probably isn't really necessary for uncomplicated pancreatitis.

 

[Vergie]

I remember Uworld having a question with the guy having uncomplicated pancreatitis and they wanted to know which test would lead to the dx and the answer was serum lipase/amylase and not abd CT (it was also a choice). So yeah I agree with turkeyjerky, gotta be careful on that one. CT will always confirm but not always needed.

 

[Captopril]

I remember Uworld having a question with the guy having uncomplicated pancreatitis and they wanted to know which test would lead to the dx and the answer was serum lipase/amylase and not abd CT (it was also a choice). So yeah I agree with turkeyjerky, gotta be careful on that one. CT will always confirm but not always needed.

hmm, I stand corrected then. Don't remember that question, but I'll keep that in mind if it comes up.

 

[ChiDO]

Had a question on mine that described gallstones basically and said due to insurance reasons you are only allowed to perform 1 diagnostic test, what would you order. Choices were CT, HIDA, ERCP....no US choice.

I went with HIDA... 🙄

 

[LouisianaDoctor]

It's pretty crazy how vague the question can be!

Cholescintigraphy (Also Called Gallbladder Radionuclide Scan or HIDA scan). Cholescintigraphy, a nuclear imaging technique, is more sensitive than ultrasound for diagnosing acute cholecystitis. It is noninvasive but can take 1 - 2 hours or longer. The procedure involves the following steps:

A tiny amount of a radioactive dye is injected intravenously. This material is excreted into bile.
The patient lies on a table under a scanning camera, which detects gamma (radioactive) rays emitted by the dye as it passes from the liver into the gallbladder.
The test can take up to 2 hours, because each image takes about a minute, and images are taken every 5 -15 minutes.
If the dye does not enter the gallbladder, the cystic duct is obstructed, indicating acute cholecystitis. The scan cannot identify individual gallstones or chronic cholecystitis.

Occasionally, the scan gives false positive results (detecting acute cholecystitis in people who do not have the condition). Such results are most common in alcoholic patients with liver disease or patients who are fasting or receiving all their nutrition intravenously.

Endoscopic Retrograde Cholangiopancreatography (ERCP). Endoscopic retrograde cholangiopancreatography (ERCP) has been the gold standard for detecting common bile duct stones, particularly because stones can be removed during the procedure. (See "Surgery" section below for a description of the procedure.)

However, this technique is invasive and carries a risk for complications, including pancreatitis. With the advent of noninvasive imaging techniques, ERCP is now generally limited to patients who have a high likelihood of common bile ducts stones, which would need to be removed. It may also be used to diagnose biliary dyskinesia.

Computed Tomography. Computed tomography (CT) scans may be a valuable additional imaging technique if the doctor suspects complications, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder. Helical (spiral) CT scanning is an advanced technique that is faster and obtains clearer images. With this process, the patient lies on a table while a donut-like, low-radiation x-ray tube rotates around the patient.

I guess the best option would have been ERCP?

 

[JimT30]

It's pretty crazy how vague the question can be!




I guess the best option would have been ERCP?

No HIDA scan is correct, ERCP if you suspect common bile duct stone, but remember that's charcot's triad.

 

[LouisianaDoctor]

No HIDA scan is correct, ERCP if you suspect common bile duct stone, but remember that's charcot's triad.

Ahhhhhhhhhh thank you 🙂

 

[kissmyasthma99]

I think this stuff can get kinda hairy, and I don't think you should just jump and say: appendicitis = CT. They want you to be able to think, not just give knee jerk reactions that every medical student in the country make. I really think they want you to think like a doctor, and know WHY you are ordering a test (and you should have a reason for every test you order). This is good practice, not just on tests, but in real life.

For example, if it's a classic presentation of acute appendicitis in a young man = there is no need to get imaging and the best next step is an appy.

However, if it has been longer than 5 days since his sx have started, you should wait on the appy, but you don't necessarily have to get a CT. The next best step would be to treat conservatively (antibiotics, NPO, IVF, etc.) followed by delayed appy.

If it's a pregnant woman = ultrasound.

If it's an atypical presentation or an old person = now you're getting to your CT. Unfortunately, you missed the 3 questions before that.

The same thing can be said for diverticulitis. If it's a classic presentation of acute diverticulitis, you don't have to get a CT (most docs will), but not on this test. If they developed complicated diverticulitis = then you get your CT. Why? Looking for things like an abscess or a perf.

I mean the list goes on...had a question about chronic pancreatitis the other day. Amylase and Lipase may be normal or just slightly elevated in chronic pancreatitis, so you can order stool elastase to look for pancreatic exocrine failure.

You also have to take into account the status of the patient. The classic example of this is a tension pneumo. Sure, the CXR is going to give you your diagnosis, but the guy is gonna die waiting for the X-ray tech to finish his coffee and donut and see who wins the showcase on the Price is Right. You gotta dart em, then put a chest tube in.

I guess what I am saying is that I don't think that jumping to a conclusion and only having one test in mind for each disease will serve you very well. I think you would be much better off to understand the disease process, the test, and why you would or wouldn't order it. To me, (just going off shelves, Uworld, and NBME practice tests) Step 2 is more about critically thinking than straight memorization. I think that is more Step 1. Just my opinion though 🙂

 

[ChiDO]

How about this scenerio....PTX with both Needle and Chest Tube answer choices...what would you pick...I'd say needle (quicker??!?!)

Also, same question, but asks what is the FIRST thing to do...chioces O2, needle, and chest tube.....I would say O2.

These are the types of questions that worry me...ones that have what appears multiple "right" answers.

 

[kissmyasthma99]

How about this scenerio....PTX with both Needle and Chest Tube answer choices...what would you pick...I'd say needle (quicker??!?!)

Also, same question, but asks what is the FIRST thing to do...chioces O2, needle, and chest tube.....I would say O2.

These are the types of questions that worry me...ones that have what appears multiple "right" answers.

Needle, then chest tube.
Needle, then chest tube.

The oxygen isn't going to help someone with a tension pneumo. You can put them on oxygen and not dart them and then watch them die.

 

[OveractiveBrain]

What is the diagnostic modality of choice for diverticulitis, pancreatitis, gallstones. I think it's CT for the first two and USG for gallstones but please correct me if I am wrong.

Also, is there a thread or another site where it lists the common diseases and their diagnostic modality and treatment of choice.

My test is in a couple of days and I am looking for some good review material.

Thanks as always!

Gallstones (you probably mean cholecystitis) - first Ultrasound, best HIDA
Choledocolithiasis - first Ultrasound (to see chole), then ERCP
Pancreatitis - Lipase and Amylase (early CT scans have a risk of making it worse)
Diverticulitis - CT scan now, Colonoscopy weeks later for diverticulosis

 

[ChiDO]

Needle, then chest tube.
Needle, then chest tube.

The oxygen isn't going to help someone with a tension pneumo. You can put them on oxygen and not dart them and then watch them die.

Or you can give them O2 first and then needle them...not sure how that person will die immediately if I don't use the needle...yet my ABC..simplest thing to do would be O2.

 

[mossyfiber12]

Thanks for the feedback guys. I am glad I am not the only one who thinks it all gets a little hard to keep track off! Good luck to you everyone on the exam...sure hope it's not like the NBME practice exams...

 

[kissmyasthma99]

Or you can give them O2 first and then needle them...not sure how that person will die immediately if I don't use the needle...yet my ABC..simplest thing to do would be O2.

You're right (in real life). However, there's a big difference between real life and a Step 2 answer, lol. For instance, almost all docs will get CTs for diverticulitis and appendicitis; however, on Step 2 for uncomplicated diverticulitis they want bowel rest and IV antibiotics and for the classic presentation of acute appendicitis in a young man, they want an appy - not a CT first.

For the pneumo. For you ABCs: your A is airway. The only things you can do in a tension pneumo to protect the airway is dart or chest tube. The air in the pleural space is compressing the airway, so you must give an outlet for the air to leave. Giving O2 will do nothing to relieve the compressed airway. In fact, high flow oxygen may actually make the pneumo worse by forcing more air into the pleural space. Mechanical ventilation with PEEP definitely will - so don't choose this option either. Intubation - the airway is patent, but is being compressed by the air in the pleural space. So again, needle then chest tube. In real life, the patient may already be receiving O2 by NC, but this isn't doing anything to help them with their pneumo. So, I wouldn't pick O2 on the test.

 

[turkeyjerky]

Or you can give them O2 first and then needle them...not sure how that person will die immediately if I don't use the needle...yet my ABC..simplest thing to do would be O2.

you really want to spend a minute futzing around w/ the nasal cannula or face mask while you watch someone die? the right answer, on the test and in real life, is needle, then chest tube.

 

[kissmyasthma99]

you really want to spend a minute futzing around w/ the nasal cannula or face mask while you watch someone die? the right answer, on the test and in real life, is needle, then chest tube.

👍

Totally agree, lol. The only thing I meant was that the person may already have a NC on. I was just trying to be a little easier on the guy 🙂