NBME Step 2 CK Form 7 Colonoscopy (NBME Answers)

NBME Step 2 CK Form 7 Answers

step2ck_form7/Block 3/Question#26 (reveal difficulty score)
A 47-year-old man comes to the physician ...
Colonoscopy 🔍 / 📺 / 🌳 / 📖
tags: GI inc

+5 upvote downvote
submitted by ∗carolebaskin(109)

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Tricky! Yes, fecal occult blood test would pick up hemorrhoid blood and this is a male <50yo, so case closed right?

Wrong! Hematocrit = 35% --> hgb = 35/3 = 11.7 < 13.5 (normal)

Why is he anemic? Do a colonoscopy.

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+2 upvote downvote
submitted by ∗lindasmith462(73)

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workup for minimal BRBPR

50+ -> colonoscopy
40-49 -> sigmoidoscopy
<40 -> no workup for low risk*

colonoscopy for any age if red flags present:

anemia
constitutional sx (fatigue, weight loss, etc)
change in bowel habits (frequency, caliber, constitution of stool)

*Of note (according to uptodate) anoscopy/proctoscopy should be considered part of the physical exam and be performed in office and would therefore technically be the correct answer here. That being said if this was a patient <40 years old w/o red flags anoscopy would be the right answer.

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azibird I was also thinking why not do anoscopy to look for internal hemorrhoids? However, even if they are present, this will not explain the anemia and colonoscopy is still needed. I've started viewing these stupid management questions as "you can only do one of these options" and it's starting to work. As in yes NEXT should be anoscopy but if I can only pick one option I'm picking colonoscopy. Another tricky angle is that it says next step in DIAGNOSIS so technically anoscopy won't ever diagnose his bleeding problem since hemorrhoids aren't the problem. +1

+1 upvote downvote
submitted by ∗seagull(1933)

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My understanding is that occult blood is commonly due to an upper GI bleed. Wouldn't the colon produce gross blood? I'm hopelessly lost in these matters.

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krewfoo99 Yeah I am lost in this one too. Maybe colonoscopy is the right answer to rule out other serious causes of GI Bleeding (Ex: Cancer). +1

happyyoyo So, hemorroidal bleeding would cause blood coating the stool. Bleeding ANYWHERE in the GI tract that eventually makes its way down to the rectum would cause OCCULT bleeding. +1

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submitted by ∗step_prep5(246)

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Key idea: Patients get their first screening colonoscopy at 50 years old, so in this patient with bowel changes (constipation) and anemia (which cannot be fully explained by hemorrhoids), the next best step would be a colonoscopy

https://step-prep.org/tutoring/

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