Help on getting better at formulating d/dx + w/u w/ MS3 almost over?

[chucklebuckle]

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Hi, I couldn't find a specific answer with the search and hoping to get some helpful guidance on what I can do. I'm a little embarrassed with the whole theme of the topic, but I think I'd be regretting this year later if I didn't anonymously ask now.

I'm almost finished with MS-3 and have been struggling (ongoing) on all my previous rotations (now in FM block) with trying to figure out how to come up with (rather than memorize) a series of differentials (and work up plans) with the patients I see either at the hospital or clinic; across all the main rotations. I have medicine (last one) coming up in a few weeks and will have to take Step 2CK+CS this summer/fall while applying to residency in September. So far, my faculty attendings have been nurturing me with the info and said not to worry as it will take time. I might be able to come up with one or two things in mind from sign/symptom/history and see a lab value or two and start from there but it's all from memorizing honestly rather than rationalizing or connecting things (ruling-in/out) from an algorithmic point of view. Books like pocket medicine and epocrates on mobile are a bit over my head at the present moment when I see those flowcharts because nothing is sinking-in and making sense... I've seen the "VITAMIN D" mnemonic before but there would be tons of blanks on trying to recall anything.

I've been using solely UW so far throughout MS-3 and I think that's the only thing that's been keeping me afloat to just barely pass each shelf rotation so far. I think my weaker 1st 2 years of pathophysiology and such has been haunting me thus far - managed to luckily pass step 1 with a 200 flat even.

Hopefully I can hear some input to reassess and come up with a new game plan during the next 3 months while doing IM rotation and beyond. Maybe I can plan some lighter electives for the next 1-2 months after IM to continue picking up with my remediation and studies. Whether it's basic books on how to build up a better differential workup to go back to or a review course, I'll take out some extra loan money to do. My biggest fear is that CK is not a memory test and I'd still like to go into Pediatrics if that's possible. My other choice was Med-Peds but I don't think my step 1 score will get me an invite but I will try with some more electives and LORS in August/September.

Sorry for the long read, but I needed to hear some advice from others who might know better. Thank you!

 

[secants]

You can try checking these books out:

Symptom to Diagnosis:

The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e:

The Merck Manual of Patient Symptoms

Usually any good textbook will have a section on how to approach symptoms and work your way to a working differential/diagnosis.

I also had this trouble and still but over time it's starting to click. But you gotta put in the time outside rotations unfortunately.

 

[tobi44]

I'm a MSII and I'm pretty worried about how I'm going to be forming differential diagnoses in third year. My plan is to pretty much memorize the mnemonics on the attached document for common symptoms and fill in information on how to distinguish between the different diseases ie labs, physical exam, imaging ect. I figure that I don't necessarily need to know the step wise algorithms exactly for working up a patient. But I do need to be able to have a conversation with an attending about what I think might be causing a certain symptom. On a different note, could any upper class man or clinicians give me some feedback on this plan?

 

[stb]

This online course might be worth a look: https://www.coursera.org/course/clinprobsolv

 

[evilbooyaa]

UWorld questions are usually asking you to determine the most likely diagnosis based on a constellation of symptoms. That is essentially the hardest part about a differential diagnosis. Throwing out 'spider bite toxin' as a DDx without a very specific history of a spider bite is going to get you laughed at.

I remember when I first started MS3 on IM, and we had a patient who had the signs of intravascular hemolysis (increased UCB, high haptoglobin). I went on UpToDate and wrote down every damn thing in the DDx for those lab values + PE findings of jaundice - From G6PD deficiency all the way to the thing that chronic bongo players get from hitting it too often. I presented it to my attending and he tried to hold back a laugh as I went farther down the differential. He told me to focus my differential on what is actually plausible, rather than everything that is possible.

I would say, start with simple stuff, like person with Hx of COPD comes in with SOB after some event yesterday - likely a COPD exacerbation. Person with Hx of MI and CAD comes in with SOB, crackles present in lungs, 2+ bilateral pedal edema - likely CHF (either primary diagnosis or exacerbation).

Best thing I would say is to learn from every patient you are seeing on FM to see how patients present. Reading about 'pain out of proportion to exam' for mesenteric ischemia is one thing. It's quite another when you see someone writhing in abdominal pain that doesn't worsen when you press down as hard as you can on their stomach. For the bread and butter stuff, that's where clinical rotations shine at teaching you how to make a diagnosis. The zebras are best learned through books unless you are lucky enough to see a case yourself.

My peds rotation had a horrible in-patient volume (0 to 2 patients on the entire peds service per day for 2 weeks), and therefore I still have problems telling the clinical difference between intussusception and malrotation and volvulus. Ditto with gastroschisis and omphalocele. I can go look these things up, but they don't stick nearly as the lady who drank close to a bottle of wine daily who came in with massive ascites, extreme jaundice, and outrageous lab values, making me remember cirrhosis and the Childs scoring (at least the basic principles behind it).

 

[tobi44]

This online course might be worth a look: https://www.coursera.org/course/clinprobsolv

Ok so I've just finished watching half the lectures for this course. I've never used coursera before but it was free, no personal information needed other then full name and email, and the instructor seemed legit so I thought I would give it a try. Its pretty good and you can watch it on double speed quickly.

So far its all about how experienced clinicians organize information so that they can recall it in an efficient way. For example, she says that instead of memorizing the laundry list of causes of headaches that you should cluster similar causes together and be able to compare/contrast those few causes. Btw, I'm heavily paraphrasing and there is a lot more to it then that.

I like it, especially since I'm at a place were I can dedicate some time to thinking about how to prep for third year. Mostly, I get the impression that organizing your memory is a good start but that the hard part is racking up experience and self study on disease. Thank you for sharing this resource.

 

[Gfliptastic]

There are books, yes. But you should really work/struggle through things on your own. It sounds really simple, but the best way to increase your "prowess" is to check out the main sections of First Aid (Step 1).

When you are presented w/ the signs and symptoms, ask yourself how each of the systems can play a role. Circulatory/cardiovascular? Neurological/nervous system? Musculoskeletal? Integumentary? Renal? Endocrine? Etc.

After you've gone thru all the systems you should already have probably a 1/2 dozen possibilities. Differentiate them 😉 based on their likelihood, or support/refute them by your physical exam. Reassess. You should be down to 3 w/ one or two really good ones. Are there labs or special tests you can do to further investigate?

If you haven't gotten any dx's at that point, go back to 1st year stuff. Can it be explained biochemically? Genetically? Anatomically?

Can you find trauma or chemical/physical causes thru a focused history-taking?

Do this, practice this repeatedly, and you should improve! Good luck!!!

 

[survivordo]

This is something that should come to you over time. I always tell my medical students 3rd year is about nailing down the history and physical, 4th year you begin to formulate a basic differential, internship and residency you nail that down. With more experience more disease processes will pop into your head automatically.

Survivor DO

 

[lauritajones]

This online course might be worth a look: https://www.coursera.org/course/clinprobsolv

Interestingly enough, Dr. Lucey is a friend of one of our faculty, so she gave us a guest lecture and afterwards I got to go to a dinner party/Q&A with her last summer. It's kind of refreshing/necessary to think about how we learn and retain information rather than just memorizing factoids all the time. I really enjoyed hearing all that she had to say. She seems like a great teacher.

 

[JShephard]

If you guys could pick one book that is the most important to learn during M3 what would it be?

Step up to medicine? Step up to medicine step 2? First Aid for step 2? First Aid for the wards?

Basically is there an equivalent to first aid for step 1?

 

[lauritajones]

I honestly did NOT think there was a FA equivalent to step 2. That being said, I found step 2 to be much easier than step 1 and my score was much higher. I used Step Up to Medicine during my medicine rotation and reviewed some of it before the test. Along the way all year, I kept up with my patients' problems on UpToDate and did UW with case files. When it came time to buckle down and study for the test, I did my leftover UW Qs and then reviewed them all. I did a couple of the practice tests, too. All in all, I was pretty happy with how that worked out for me.