Preparation for "What would you do next" question

[enigmalti]

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This is becoming more prevalent for step 1 (especially on the COMLEX). How do you go about to prepare for this step 2-esque type of question? Are there any resources we could use for this?

 

[stevesteve123]

wut...

 

[DrEnderW]

wut...

Pretty straightforward question Steve...

What are some good resources for the "what's the next step" style clinical questions that are traditionally seen more commonly in Step 2 but are now increasingly appearing on Step 1?

 

[enigmalti]

wut...

Example: pt is suspected w/ colorectal cancer...what's the best initial screening test? Or a pt is dx w/ colorectal cancer, what test would you would run next?

 

[dfib slim]

Unless the topics make it into the standard UFAP materials you risk chasing low yield information.

I'd say RR path would be the best bet.

 

[seminoma]

Example: pt is suspected w/ colorectal cancer...what's the best initial screening test? Or a pt is dx w/ colorectal cancer, what test would you would run next?

This is unrealistic because the next step depends on more than "suspected colorectal cancer." Do you suspect colorectal cancer because you found a polyp on screening colonoscopy? Next step is to biopsy it. Patient is diagnosed with colorectal cancer.. how? 1000s of polyps on colonoscopy? Complete colectomy is the next step. Patient has a proximal colon biopsy come back positive for cancer with family history of ovarian cancer and SCC? Next step is probably genetic testing of family.

Patient has high grade CIN/CIS on pap smear. What do you do next? Cytoscopy and biopsy.

30 year old woman is worried that she hasn't had a menstrual period for 10 weeks even though she has been fairly regular since age 15. What do you do? Pregnancy test.

16 year old boy presents with unilateral gynecomastia, but otherwise normal tanner development. What do you do? Nothing, it's normal.

80 year old man presents painless hematuria and used to work in a rubber factory. What do you do? cystoscopy.

17 year old girl with history of an eating disorder presents with metabolic alkalosis and is stable. What do you do? Check urine chloride.

They aren't step 2 questions. They are "do you understand the consequences for the patient/patient family or did you just memorize bullet points from FA?" questions.

Knowing the "next best step" hinges on knowing the pathophys, epidemiology, and general info about treatment modalities. The only way to prepare for them is to know your ****.

 

[Jabbed]

These "clinical management" questions are just pre-clinical questions in disguise. Identifying the pathology and mechanism of disease should significantly narrow down the answer choices.

 

[Planes2Doc]

We had a bunch of these in our clinical medicine class. Fortunately, a lot of them had answer choices which were so whacky, that you knew they were wrong. But yeah, I agree with seminoma, it's testing to see whether you know your stuff or not. I think this would, however, be a good answer in a lot of cases:

 

[enigmalti]

This is unrealistic because the next step depends on more than "suspected colorectal cancer." Do you suspect colorectal cancer because you found a polyp on screening colonoscopy? Next step is to biopsy it. Patient is diagnosed with colorectal cancer.. how? 1000s of polyps on colonoscopy? Complete colectomy is the next step. Patient has a proximal colon biopsy come back positive for cancer with family history of ovarian cancer and SCC? Next step is probably genetic testing of family.

Patient has high grade CIN/CIS on pap smear. What do you do next? Cytoscopy and biopsy.

30 year old woman is worried that she hasn't had a menstrual period for 10 weeks even though she has been fairly regular since age 15. What do you do? Pregnancy test.

16 year old boy presents with unilateral gynecomastia, but otherwise normal tanner development. What do you do? Nothing, it's normal.

80 year old man presents painless hematuria and used to work in a rubber factory. What do you do? cystoscopy.

17 year old girl with history of an eating disorder presents with metabolic alkalosis and is stable. What do you do? Check urine chloride.

They aren't step 2 questions. They are "do you understand the consequences for the patient/patient family or did you just memorize bullet points from FA?" questions.

Knowing the "next best step" hinges on knowing the pathophys, epidemiology, and general info about treatment modalities. The only way to prepare for them is to know your ****.

The answer to the first question was hemocult in stool (reason -- least expensive and least invasive so it is best for initial test) and the latter was abdominal CT (in case of metastasis). These are the questions coming from my qbank. These types of question always stump me...they're logical but I always narrow down to 50/50 and pick the wrong one. Like a pt w/ Homan sign, what would you do next? Give him anticoag or compression ultrasound? I picked anticoag.

 

[pd1112]

The answer to the first question was hemocult in stool (reason -- least expensive and least invasive so it is best for initial test) and the latter was abdominal CT (in case of metastasis). These are the questions coming from my qbank. These types of question always stump me...they're logical but I always narrow down to 50/50 and pick the wrong one. Like a pt w/ Homan sign, what would you do next? Give him anticoag or compression ultrasound? I picked anticoag.

You either just know it or you spend hours on uptodate looking up every disease to figure it out. If it's on Step1 and a management question, it's probably going to be fairly obvious. Would you really anticoag someone based on PEx with no imaging?

 

[Jabbed]

The answer to the first question was hemocult in stool (reason -- least expensive and least invasive so it is best for initial test) and the latter was abdominal CT (in case of metastasis). These are the questions coming from my qbank. These types of question always stump me...they're logical but I always narrow down to 50/50 and pick the wrong one. Like a pt w/ Homan sign, what would you do next? Give him anticoag or compression ultrasound? I picked anticoag.

Homan's sign is the most insensitive/non-specific BS around. That question basically relied on you discerning that you should order an ultrasound study over anticoagulating a patient whom has a low/medium risk of DVT.

 

[seminoma]

The answer to the first question was hemocult in stool (reason -- least expensive and least invasive so it is best for initial test) and the latter was abdominal CT (in case of metastasis). These are the questions coming from my qbank. These types of question always stump me...they're logical but I always narrow down to 50/50 and pick the wrong one. Like a pt w/ Homan sign, what would you do next? Give him anticoag or compression ultrasound? I picked anticoag.

Yeah of course it's going to depend on the full scenario. Usually you should go with the least invasive, lowest risk option first.

A stable patient with a positive Homan sign and no signs of respiratory distress really doesn't need immediate anticoagulation. You would confirm the suspected DVT with the US and if they're asymptomatic and are a low risk patient (no history, no coagulopathy, not old, etc) you don't even need to anticoagulate them if the DVT is isolated to the calf (vs more proximal). Those patients just get monitored every week or two with repeat US to make sure the DVT isn't extending proximally. For Step 1 we probably don't have to know how to manage a DVT isolated to the calf in an asymptomatic low-risk patient, though. We just have to know that you don't start someone on anticoagulants just because it hurts when you squeeze their calf and dorsiflex their foot. I have a positive Homan almost every day following leg day. Doesn't mean I have a DVT.

 

[Transposony]

It's a judgement call. So no book can do, only common sense.

 

[Focused1]

The answer to the first question was hemocult in stool (reason -- least expensive and least invasive so it is best for initial test) and the latter was abdominal CT (in case of metastasis). These are the questions coming from my qbank. These types of question always stump me...they're logical but I always narrow down to 50/50 and pick the wrong one. Like a pt w/ Homan sign, what would you do next? Give him anticoag or compression ultrasound? I picked anticoag.

Your QBank ? What does that mean ? Kap UW Rx ?

 

[fmestep1]

I think the best way is to probably just do more uworld questions. Most 2 step questions I have encountered on uworld are the treatment questions or the side effects questions.