Work up / diagnostic studies in Step 2 cs

[Sir Gillies]

Hi guys,

I have a question about the extent of work up that requires to be inserted in step 2 cs. FA suggests rather in depth tests that would not necessarily be done immediately.

For example, chest pain they suggest to perform:
1. ECG
2. Cardiac enzymes (CPK, CPK-MB, troponin)
3. CXR
4. Transthoracic echocardiogram
5. Cardiac catheterization
6. Transesophageal echocardiogram
7. CT - chest with IV contrast
8. Upper endoscopy
9. Cholesterol panel

If I had to deal with this pt in hospital I would start with the first 3 + medical Tx whilst waiting for the results and only if +ve for STEMI I would move on to catheterization.

I would be really grateful if someone could kindly explain to me the extent of work up that I have to put down.
Thanks a lot in advance.

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[Transposony]

Just put first 8 which comes to your mind preferably in order of importance depending on your differential.
For example, I would put:
1. ECG
2. CPK, CPK-MB, troponin
3. CXR
4. Echocardiogram
5. CT - chest
6. Cholesterol panel
7. Upper endoscopy
8. CBC, UA, PT, PTT

 

[Sir Gillies]

So, what you are saying is that I should list all the tests that would be required to diagnose/rule out what is in my differential, rather than what would be the first step.

Can anyone confirm... Thanks a lot in advance.

 

[Transposony]

So, what you are saying is that I should list all the tests that would be required to diagnose/rule out what is in my differential, rather than what would be the first step.

Can anyone confirm... Thanks a lot in advance.

Yes. You should put the most important investigation first as you may not know when the time is going to run out for PNs.

Step 3 tests the order of the investigations.

 

[Sir Gillies]

Sorry did you mean step 2cs... That's what I'm preparing for : )

I am going through cases now and I really need to get into the right mindset because I feel that I'm under investigating... It just feels weird to order for a kid a CT abdo and do an LP when the case leads to malingering... LoL

Thanks a lot for your input.

 

[Transposony]

Sorry did you mean step 2cs... That's what I'm preparing for : )

I am going through cases now and I really need to get into the right mindset because I feel that I'm under investigating... It just feels weird to order for a kid a CT abdo and do an LP when the case leads to malingering... LoL

Thanks a lot for your input.

What I meant was that for CS you can put the investigations in any order (preferably the most important first since you don't want to miss the most important investigation for the patient note if you run out of time for whatever reason). Step 3 tests your knowledge of doing investigations in the correct order, so, don't worry about that in CS.
CS is not about knowledge, it is a test of your acting ability & typing skills. So, don't worry about ordering CT scan & LP in a kid. Write whatever is indicated to rule in or out a differential (even if it is not among the three differential you are allowed to write in the provided space).
e.g. in an abd pain case when your differential is Biliary colic, acute cholecystitis and Gastritis you would still write CT abdomen, amylase/lipase etc to r/o Pancreatitis.

 

[Sir Gillies]

Thank very much for the clarification! Will do : )

 

[Sir Gillies]

One more question for those who have already passed 2 cs...

Someone suggested I could write multiple investigations on each line of the workup section. For example:
- 1st line: all blood tests eg CBC, electrolytes, etc
- 2nd line: all radiological tests eg CT head, MRI head, US carotids
And so on...

Does someone have experience in doing so end passing comfortably? Would you advice against it?

 

[eastcoastdr]

What I meant was that for CS you can put the investigations in any order (preferably the most important first since you don't want to miss the most important investigation for the patient note if you run out of time for whatever reason).

This is a good way of thinking about it. Your first two or three tests should always be the basic routine ones (CBC, electrolytes, UA, CXR) but dont forget to add in a few more important relevant tests that will help you rule in/rule out.

I think FA goes a little overboard in it's patient note section..I believe they write a very inclusive, "perfect" note and you should do your best to write down MOST, not all, of what they do in their note. All tests they write down are possible correct answers. I tried to aim for at least 5 of what they listed.

Also I found that during my exam, some of the patients had very specific trauma related musculoskeletal injuries - therefore it was kinda difficult to even think of diagnostic tests aside from XR, CT, MRI. So don't worry about being able to list 8-10 different tests, most of the time you literally won't be able to think of that many for that certain patient!

 

[Sir Gillies]

Thanks a lot for the reply. What do you think of writing multiple tests on each line? That would save time, but not sure whether it is allowed...

 

[eastcoastdr]

Thanks a lot for the reply. What do you think of writing multiple tests on each line? That would save time, but not sure whether it is allowed...

I only grouped together basic lab tests. I believe thats what First Aid did. I always grouped CBC/electrolytes together, UA/UCx together. I never grouped imaging together..always kept CTs, XRays, sonos and MRIs on separate lines. I also kept the "forbidden" tests on separate lines (breast exam, pelvic exam, and rectal exam).

 

[Hemichordate]

When you list diagnosis, do you have to list 3 or can you just do 2?

 

[Thereisaspoon]

Just put first 8 which comes to your mind preferably in order of importance depending on your differential.
For example, I would put:
1. ECG
2. CPK, CPK-MB, troponin
3. CXR
4. Echocardiogram
5. CT - chest
6. Cholesterol panel
7. Upper endoscopy
8. CBC, UA, PT, PTT

The problem with this philosophy is that the Step 2 CS manual clearly states that you will lose points for overly aggressive testing.

Any Thoughts?

 

[Transposony]

The problem with this philosophy is that the Step 2 CS manual clearly states that you will lose points for overly aggressive testing.

Any Thoughts?

That should be the least of your worries since in practice you will not have enough time to write it all.
What Step 2 CS manual implies is that you can't shoot in the dark hoping that one of them will hit the target.
For example, someone writes same set of 20 tests for every case among which some of those will fit the D/D in each case.

 

[Thereisaspoon]

That should be the least of your worries since in practice you will not have enough time to write it all.
What Step 2 CS manual implies is that you can't shoot in the dark hoping that one of them will hit the target.
For example, someone writes same set of 20 tests for every case among which some of those will fit the D/D in each case.

Not exactly. If you look at the USMLE manual example notes, they ding a note for ordering a CT which could be appropriate if the first 3 DDx are not the diagnosis after a initial workup.

On their 28yo Dyspareunia case.. the recommend laparoscopy as part of their dx workup -- this is insane when you consider vulvovaginitis and cervicitis is on the same ddx. Can you imagine meeting a dyspareunia pt in the ED and recommending laparoscopy. That is absurd!

Further, my problem with FA is that their workups don't always match their 3 DDx. For example, in the FA fatigue case they order a CBC though they do not have anemia on the DDx. The CBC is totally reasonable but anemia is not listed because it is less likely given the presention.

 

[Thereisaspoon]

Another example is the last case in the book. They recommend an EEG as part of the w/u. You would never order an EEG from the ED for a patient who likely has either dysrhythmia, orthostatic/vasovagal syncope, etc.