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  #1  
Old 05-21-2013
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Default Ruling out diseases not listed in your diagnosis

I've searched around for the answer to my question, but I cant seem to find it. I apologize in advance if this has already been asked.

Since we can only list 3 dx, are we still supposed to rule out things with workups that are possible but didnt make the the cut.

Example:
Women with abdominal pain.
If my Dx. are 1. PUD 2. Gastritis 3. cholecystitis

I would put rectal, occult blood, cbs, ultrasound abdomen, endoscopy as my workup, but should I add AST ALT ALKP Lipase, to rule out pancreatitis, hepatitis?

Or if my Dx were. 1. Ectopic 2. Ovarian torsion 3. appendicitis

I would put pelvic, rectal, cbc, urine hcg, ultrasound pelvis and abdomen, Ct scan abdomen, laparatomy... Should I add AST ALT (hepatitis) or anything else to rule out other possible causes? Like barium enema, cervical swab, UA, Urine culture and gram stain etc. ?
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  #2  
Old 05-21-2013
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Quote:
Originally Posted by faizamaze View Post
I've searched around for the answer to my question, but I cant seem to find it. I apologize in advance if this has already been asked.

Since we can only list 3 dx, are we still supposed to rule out things with workups that are possible but didnt make the the cut.

Example:
Women with abdominal pain.
If my Dx. are 1. PUD 2. Gastritis 3. cholecystitis

I would put rectal, occult blood, cbs, ultrasound abdomen, endoscopy as my workup, but should I add AST ALT ALKP Lipase, to rule out pancreatitis, hepatitis?

Or if my Dx were. 1. Ectopic 2. Ovarian torsion 3. appendicitis

I would put pelvic, rectal, cbc, urine hcg, ultrasound pelvis and abdomen, Ct scan abdomen, laparatomy... Should I add AST ALT (hepatitis) or anything else to rule out other possible causes? Like barium enema, cervical swab, UA, Urine culture and gram stain etc. ?
Good question. I am also confused with the same problem. Looking forward to anyone's suggestion. Thanks!
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Old 05-21-2013
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Quote:
Originally Posted by faizamaze View Post
I've searched around for the answer to my question, but I cant seem to find it. I apologize in advance if this has already been asked.

Since we can only list 3 dx, are we still supposed to rule out things with workups that are possible but didnt make the the cut.

Example:
Women with abdominal pain.
If my Dx. are 1. PUD 2. Gastritis 3. cholecystitis

I would put rectal, occult blood, cbs, ultrasound abdomen, endoscopy as my workup, but should I add AST ALT ALKP Lipase, to rule out pancreatitis, hepatitis?

Or if my Dx were. 1. Ectopic 2. Ovarian torsion 3. appendicitis

I would put pelvic, rectal, cbc, urine hcg, ultrasound pelvis and abdomen, Ct scan abdomen, laparatomy... Should I add AST ALT (hepatitis) or anything else to rule out other possible causes? Like barium enema, cervical swab, UA, Urine culture and gram stain etc. ?
I don't see how adding workup should be detrimental to your score, as long as it is pertinent to your case. There is no minimum for diagnostic workup but for the safe side try to use up the 3 boxes given. Personally, for my exam I stuck to the diagnostic workup pertinent to my different dx and for most of them I had 4-5. Maybe for one or two did I additional (like you mentioned).
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  #4  
Old 05-21-2013
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Wont hurt you.. as long as it makes sense.. however you should focus on first ruling out the DDx you put in your PN and then if you have time you can put extra stuff
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Old 05-22-2013
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Default 8 boxes

For the diagnostic work up there are 8 rows that can be added , so as long as your initial workup is pertinent to your differential and you have enough rows left you can put in those other tests that you want to mention
remember only 8 rows maximum for the work up!
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Old 05-22-2013
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Have you looked at the PN example in the USMLE step 2 clinical skills booklet?
they only wrote 2 differential diagnosis and on the physical they wrote only one supporting PE. and on the work up, they wrote only one test for each differential diagnosis. so my opinion according to the USMLE BOOKLET just write the most likely diagnosis (up to 3 from most to least likely), enter the positive or negative findings (if present)and THE INITIAL diagnostic studies including the restricted physical exam maneuvers. you don't have to rule out every single differential, ONLY the most likely ones that you choose
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Quote:
Originally Posted by us2012 View Post
Have you looked at the PN example in the USMLE step 2 clinical skills booklet?
they only wrote 2 differential diagnosis and on the physical they wrote only one supporting PE. and on the work up, they wrote only one test for each differential diagnosis. so my opinion according to the USMLE BOOKLET just write the most likely diagnosis (up to 3 from most to least likely), enter the positive or negative findings (if present)and THE INITIAL diagnostic studies including the restricted physical exam maneuvers. you don't have to rule out every single differential, ONLY the most likely ones that you choose
This is something that is the MINIMUM required in order to write an acceptable Patient note....
First aid, Kaplan and other sources encourage to write as much as possible as long as it makes sense and you did it..
Remember the difficulty has increased dramatically.. AMGs and IMGs are falling like flies and every tiny detail counts... I'd rather write more than just the mininum.. IM pretty sure If I have done that in my exam I would've failed

It is not about ruling out every single tiny differential.. it is about ruling out the 3 more likely diagnoses and if you can rule out a couple more then DO IT.. they put 8 rows for a reason.. USE THEM
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My opinion was not to write only the minimum but you should write the work up only for the differential diagnosis that you come up with. for the example that the doctor wrote above, why should I rule out pancreatitis if it's not in my differential diagnosis. i think if I'm going to write diagnostic studies for certain diagnosis, I should include it under my differential diagnosis list otherwise why should I rule out something that I don't have on my list in the first place. This is just an opinion, and I surely could be mistaken. we all are just trying our best and good luck to all of us.
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Quote:
Originally Posted by us2012 View Post
My opinion was not to write only the minimum but you should write the work up only for the differential diagnosis that you come up with. for the example that the doctor wrote above, why should I rule out pancreatitis if it's not in my differential diagnosis. i think if I'm going to write diagnostic studies for certain diagnosis, I should include it under my differential diagnosis list otherwise why should I rule out something that I don't have on my list in the first place. This is just an opinion, and I surely could be mistaken. we all are just trying our best and good luck to all of us.
It is ok that it is your opinion.. but if you have a female patient with RUQ pain that you suspect is acute cholecystitis and she also has a fever and then you put as differentials acute cholangitis and choledocholithiasis and you dont do a workup for acute pancreatitis then you are wrong on so many levels.

You have to rule out your differentials diagnoses and if you have time you can rule out more stuff... im not saying you have to do it everytime but if you can you SHOULD do it.. therefore i believe you are wrong.

Peace
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Quote:
Originally Posted by us2012 View Post
why should I rule out pancreatitis if it's not in my differential diagnosis
Because PNs are scored by MD's and missing pancreatitis (however unlikely it may seem) will be like a death sentence for the patient and your medical career.
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Quote:
Originally Posted by Novobiocin View Post
Because PNs are scored by MD's and missing pancreatitis (however unlikely it may seem) will be like a death sentence for the patient and your medical career.
Dude this post is not about pancreatitis, I just used the same example in the original post to prove a point, that's all. The original question is: should we write diagnostic studies to rule out disorders that we didn't include in our differential diagnosis list or not.
For me If I think pancreatitis (for example) is a possibility, I'd include it in my differential diagnosis list and put the diagnostic studies for it.
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Quote:
Originally Posted by us2012 View Post
Dude this post is not about pancreatitis, I just used the same example in the original post to prove a point, that's all. The original question is: should we write diagnostic studies to rule out disorders that we didn't include in our differential diagnosis list or not.
Exactly DUDE, I also used the same example you used from the original post to prove my point. I CAN READ so I did read the original post. So that you can understand let me enlighten you from the original post:
Quote:
Example:
Women with abdominal pain.
If my Dx. are 1. PUD 2. Gastritis 3. cholecystitis
The three DD by OP does not include Pancreatitis BUT you still have to rule it out when you are considering cholecystitis in the differential since pancreatitis is a very serious condition and undiagnosed/untreated pancreatitis can be fatal so you must rule it out. In fact in all three DD mentioned by OP you must rule out pancreatitis. Since there are only 3 DD you can put in PN you have no choice but to put tests to rule out the other differentials under workup.
I hope it is clear DUDE!
Quote:
Originally Posted by us2012 View Post
For me If I think pancreatitis (for example) is a possibility, I'd include it in my differential diagnosis list and put the diagnostic studies for it.
Wow DUDE, how come I couldn't think of that!
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