Is my whole life a lie? (CSSA form 7)

[SpecterGT260]

Seriously... I am working through the ones I missed and between myself, uptodate, and about a dozen prep books, and good ol fashioned google, I cannot come up with why most of these are wrong. I did pretty well on step1 and have been hitting at or above average on the random UWorld sets I do. Anyone else do this assessment and feel like they ask some pretty random crap with some pretty ridiculous stems? Also... I feel like several of their answers are just plain wrong...

You do get yourself a quick Doppler US when suspecting testicular torsion prior to calling the surgeon, right?

For suspected meningitis, LP > Head CT and LP should be first, right?

I'm sure I'll come across some others that I just cannot reconcile as I go through this...

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[mastmastdonan]

Yeah man it was definitely a tough one. Are we allowed to go through questions on this forum? I'm confused on quite a few as well.

 

[SpecterGT260]

Yeah man it was definitely a tough one. Are we allowed to go through questions on this forum? I'm confused on quite a few as well.

I don't know the specific rules about discussing questions which is why I phrased it as general points.

 

[SpecterGT260]

Although looking online said that it under predicts because its a d-baggy test. So that is reassuring.

 

[UMN]

Hated that form. I feel like 30% answers that i got wrong, should've been right. Got a 231 on it last week. Nbme 4 3 weeks ago was 252. Score dropped 21 pointsss

 

[SpecterGT260]

Hated that form. I feel like 30% answers that i got wrong, should've been right. Got a 231 on it last week. Nbme 4 3 weeks ago was 252. Score dropped 21 pointsss

I just picked up form 4 for this weekend. We will see how it goes.

 

[UMN]

I just picked up form 4 for this weekend. We will see how it goes.

Good luck. Im sure ur score will increase by at least 10-15 points on form 4.

 

[SpecterGT260]

Ugh... I'm getting super pissed at this test. postpartum bleeding. Most common cause is atony, right? Except they tell us that the placenta is intact but torn. Do we ignore this info which might point toward uterine inversion (my incorrect answer)? What about retained placenta? Do we just assume they are lying about the intact part? When you throw out a question and you want epidemiology-based answers, don't include unnecessary information... Or how about that picture of, I assume genital herpes, that doesn't have a single herpetic lesion in frame. They are all ulcers. This ambiguous nonsense is just bad test writing.... Although maybe I could argue that some of my school's tests should have prepared me for this...

 

[scummie]

Just wanted to say I love your profile pic. Loved playing that game when I was a kid. RIP Windows 95.

 

[DocDO2B]

Since the consensus is that the new nbme 7 is a complete failure, which nbme should I take if I have already taken nbme 4? Im saving the uw exam for closer to my exam.

 

[SpecterGT260]

Since the consensus is that the new nbme 7 is a complete failure, which nbme should I take if I have already taken nbme 4? Im saving the uw exam for closer to my exam.

Does the UW exam come with the qbank? I can't remember if I have it by default or not. I do questions on my phone so I rarely log in to their website

 

[DocDO2B]

It doesnt. Its $25 extra

 

[thehundredthone]

You can paraphrase the question with the answers choices that you had doubts about. That would also help those of us who haven't taken the form but have written Step 2 already to try and answer your questions.

 

[mastmastdonan]

I think for testicular torsion you go for immediate surgery

 

[SpecterGT260]

Every resource I have checked says to go to surgery without waiting for further tests IF the US shows decreased flow.

This kid also had abdominal pain and guarding which might change it, but they focused the whole history on his balls and mentioned discoloration of the left hemiscrotum (blue dot sign?)

The issue is that I haven't seen anything that gives a good guideline for when clinical suspicion is enough to not justify a 30 sec US.

 

[DrAcula_MD]

Every resource I have checked says to go to surgery without waiting for further tests IF the US shows decreased flow.

This kid also had abdominal pain and guarding which might change it, but they focused the whole history on his balls and mentioned discoloration of the left hemiscrotum (blue dot sign?)

The issue is that I haven't seen anything that gives a good guideline for when clinical suspicion is enough to not justify a 30 sec US.

My gut reflex would have been to go with US first as well. But now that I look at it, SUTM and Pestansa do both say go straight to surgery based on clinical presentation.**sigh**. Hope that's helpful.

 

[SpecterGT260]

My gut reflex would have been to go with US first as well. But now that I look at it, SUTM and Pestansa do both say go straight to surgery based on clinical presentation.**sigh**. Hope that's helpful.

Par for the course I guess. I got the above answer from Master the Boards and First Aid. Regardless, its absurd to have 2 right answers on a question. Oh well

 

[DrAcula_MD]

Par for the course I guess. I got the above answer from Master the Boards and First Aid. Regardless, its absurd to have 2 right answers on a question. Oh well

Agreed. There's definitely more shades of gray on this exam as compared to Step 1, with some inconsistencies even between the resources. I'll be glad when it's over!

 

[mercaptovizadeh]

On surgical questions, especially, if the index of suspicion is high enough, you go straight to surgery. If you think a toddler has malrotation and volvulus, you do not wait for a upper GI with small bowel follow through study. You go to the OR. Likewise, if appendicitis is very strongly suggested clinically, you can even skip doing the abdominal CT scan and go straight to OR, since you will go to the OR regardless of what the CT shows based on clinical picture.

So, the testicular torsion question falls under that.

For meningitis, you do CT first to confirm that the ICP is not too high and the patient won't herniate. If ICP is not markedly elevated (e.g. hydrocephalus), you can then proceed to LP.

Regarding the placenta, if you see that it was torn you must keep in mind the possibility that retained placenta is causing the ongoing bleeding. I would say uterine atony is generally the most common cause of post-partum hemorrhage. Uterine inversion would leave some other mark, such as not feeling a small globular uterus on exam and perhaps seeing some endometrium coming out the vagina.

 

[Bagheera]

For the meningitis pt, did the question stem mention that patient exhibiting any focal neurological deficits? seizures? papiledema? In that case you would do a CT of the head before LP to rule out if the patient has any mass or increase ICP. Otherwise, you could a LP without a CT scan in most other cases.

 

[SpecterGT260]

On surgical questions, especially, if the index of suspicion is high enough, you go straight to surgery. If you think a toddler has malrotation and volvulus, you do not wait for a upper GI with small bowel follow through study. You go to the OR. Likewise, if appendicitis is very strongly suggested clinically, you can even skip doing the abdominal CT scan and go straight to OR, since you will go to the OR regardless of what the CT shows based on clinical picture.

So, the testicular torsion question falls under that.

I've been burned on this for appendicitis before by answering "surgery" when offered the choice to get CT. I think it is safer to always get the abdominal CT on these questions if they are hemodynamically stable. If they look like they are going septic just go to the OR. That said, I don't recall the vitals of the kid with torsion

For meningitis, you do CT first to confirm that the ICP is not too high and the patient won't herniate. If ICP is not markedly elevated (e.g. hydrocephalus), you can then proceed to LP.

Regarding the placenta, if you see that it was torn you must keep in mind the possibility that retained placenta is causing the ongoing bleeding. I would say uterine atony is generally the most common cause of post-partum hemorrhage. Uterine inversion would leave some other mark, such as not feeling a small globular uterus on exam and perhaps seeing some endometrium coming out the vagina.

That is the issue though... using that exact (quite literally) thought process, the answer is still a flip of a 3-sided coin. Should the question come up again, the above gives no indication on what to do other than re-roll the dice. We either have to assume that they are wrong about the "appears complete" part, which is inappropriately misleading, or we assume the tear itself is simply irrelevant, which is dangerous to do on a boards question where the correct answer is not infrequently decided by 1-2 words hidden in a wall of text in the question.
It's just a crappy question. It happens.

p.s. just got done with form 4 and scored a projected 235 which is way closer to what I expected. Got a couple areas to brush up on and I should be in a good spot in a few weeks.

 

[thehundredthone]

1. For questions on surgery vs investigation, think about haemodynamic stability, the time since onset of symptoms, necessity of investigation to confirm diagnosis (and avoid surgery), and the time required for investigations (and how it links in with time since onset of symptoms).

2. In meningitis, the only reason to delay the LP is if there are signs of raised ICP (papilloedema, neurological deficit, seizures, altered mental status) except in infants, or contraindications to the procedure itself (bleeding disorders whether primary or secondary). If you delay the LP for any reason then give empirical antibiotics first, then send the patient for the CT if relevant.

3. While the retained placenta may be a risk for inversion, atony is a risk factor for retained placenta. Chicken and egg. Inversion usually results along with retained placenta due to morbid adherence of the placenta or improper traction, the retained bit in of and itself doesn't cause the inversion. Also, how can the placenta be intact but torn, are you sure that's what the question said?

 

[SpecterGT260]

1. For questions on surgery vs investigation, think about haemodynamic stability, the time since onset of symptoms, necessity of investigation to confirm diagnosis (and avoid surgery), and the time required for investigations (and how it links in with time since onset of symptoms).

2. In meningitis, the only reason to delay the LP is if there are signs of raised ICP (papilloedema, neurological deficit, seizures, altered mental status) except in infants, or contraindications to the procedure itself (bleeding disorders whether primary or secondary). If you delay the LP for any reason then give empirical antibiotics first, then send the patient for the CT if relevant.

3. While the retained placenta may be a risk for inversion, atony is a risk factor for retained placenta. Chicken and egg. Inversion usually results along with retained placenta due to morbid adherence of the placenta or improper traction, the retained bit in of and itself doesn't cause the inversion. Also, how can the placenta be intact but torn, are you sure that's what the question said?

They might have said "complete". Either way, there was clear language that made retained parts unlikely.

 

[DocDO2B]

I've been burned on this for appendicitis before by answering "surgery" when offered the choice to get CT. I think it is safer to always get the abdominal CT on these questions if they are hemodynamically stable. If they look like they are going septic just go to the OR. That said, I don't recall the vitals of the kid with torsion

That is the issue though... using that exact (quite literally) thought process, the answer is still a flip of a 3-sided coin. Should the question come up again, the above gives no indication on what to do other than re-roll the dice. We either have to assume that they are wrong about the "appears complete" part, which is inappropriately misleading, or we assume the tear itself is simply irrelevant, which is dangerous to do on a boards question where the correct answer is not infrequently decided by 1-2 words hidden in a wall of text in the question.
It's just a crappy question. It happens.

p.s. just got done with form 4 and scored a projected 235 which is way closer to what I expected. Got a couple areas to brush up on and I should be in a good spot in a few weeks.

I just did form 7 and apparently retained placenta is also WRONG! I don't know what they wanted on this question if atony AND retained placenta are both wrong

 

[UMN]

Answer was Uterine Atony. The question mentioned that the uterine fundus was palpated 3 cm above the umbilicus, she had a 9lb baby, and the placenta was COMPLETE but torn. A minor tear in the placenta could be a normal finding.

 

[SpecterGT260]

Answer was Uterine Atony. The question mentioned that the uterine fundus was palpated 3 cm above the umbilicus, she had a 9lb baby, and the placenta was COMPLETE but torn. A minor tear in the placenta could be a normal finding.

They don't show you your correct answers. So you either have copies of the questions and your answers, a photographic memory, or you used process of elimination based on my and the other guy's wrong answers to arrive at the correct one.

 

[UMN]

I took it b4 u took the nbme. I even told u like a week ago that i didn't do too good on it. The questions r posted on the usmle-forums. Just looked up that question coz i remember contemplating about those 2 options. I eventually got it right but wasn't a 100% sure on wat I chose at the end. Sorry didn't mean to start an argument.. was jus tryin to help wit the explanation.

 

[SpecterGT260]

I took it b4 u took the nbme. I even told u like a week ago that i didn't do too good on it. The questions r posted on the usmle-forums. Just looked up that question coz i remember contemplating about those 2 options. I eventually got it right but wasn't a 100% sure on wat I chose at the end. Sorry didn't mean to start an argument.. was jus tryin to help wit the explanation.

I wasn't either. I was hoping you had the whole test w answers somewhere

 

[UMN]

Look em up on the usmleforums. Some parts of the questions r posted thr.

 

[thehundredthone]

Answer was Uterine Atony. The question mentioned that the uterine fundus was palpated 3 cm above the umbilicus, she had a 9lb baby, and the placenta was COMPLETE but torn. A minor tear in the placenta could be a normal finding.

Makes sense now. That's classic atony. Can't have inversion with a fundus that high up anyway.

They don't show you your correct answers. So you either have copies of the questions and your answers, a photographic memory, or you used process of elimination based on my and the other guy's wrong answers to arrive at the correct one.

Isn't there extended feedback on the form? Anyone that didn't have the question show up on the feedback would then know what the correct answer was.

 

[SpecterGT260]

Makes sense now. That's classic atony. Can't have inversion with a fundus that high up anyway.


Isn't there extended feedback on the form? Anyone that didn't have the question show up on the feedback would then know what the correct answer was.

But citing the weight of the baby and specifics of the PE is sideshow level memory.

 

[thehundredthone]

But citing the weight of the baby and specifics of the PE is sideshow level memory.

Someone who got it wrong posted it somewhere else where they put down the whole question verbatim? These questions are discussed all over the internet, as he has mentioned above my previous post.

 

[SpecterGT260]

Someone who got it wrong posted it somewhere else where they put down the whole question verbatim? These questions are discussed all over the internet, as he has mentioned above my previous post.

*facepalm*

What exactly is your point? If you would do yourself and everyone else a favor and read above as your post here suggests you have, you'd quickly see that this has already been established between myself and the poster who gave those facts. You asked about the rationale behind my post. I gave it. Move on

 

[thehundredthone]

What exactly is your point? If you would do yourself and everyone else a favor and read above as your post here suggests you have, you'd quickly see that this has already been established between myself and the poster who gave those facts. You asked about the rationale behind my post. I gave it. Move on

Calm down. All I did was reply to your statement about slideshow memories.

 

[SpecterGT260]

Calm down. All I did was reply to your statement about slideshow memories.

Sideshow. I.e. "circus". It was a response to your question. You reiterated what was already known and understood. I'm not sure what the purpose of the reply was. If it was purposeless, then say so and let's move on.

 

[laboholic]

Form 7 was tough. Anyone know the answer to this:
Young guy took some kind of drug. He has constricted pupils, bilat nystagmus, hypertonia.... blank stare, not talking, not reactive to pain.
1. stimulant
2. heroin
3. inhalant
4. PCP
5. Alcohol
6. Hallucinogen

The answer isn't heroin.
The constricted pupils are throwing me off

 

[SpecterGT260]

Form 7 was tough. Anyone know the answer to this:
Young guy took some kind of drug. He has constricted pupils, bilat nystagmus, hypertonia.... blank stare, not talking, not reactive to pain.
1. stimulant
2. heroin
3. inhalant
4. PCP
5. Alcohol
6. Hallucinogen

The answer isn't heroin.
The constricted pupils are throwing me off

Nystagmus = PCP (or etoh if they neglect to tell you direction). It got me too.

 

[Drskillz1]

Form 7 was tough. Anyone know the answer to this:
Young guy took some kind of drug. He has constricted pupils, bilat nystagmus, hypertonia.... blank stare, not talking, not reactive to pain.
1. stimulant
2. heroin
3. inhalant
4. PCP
5. Alcohol
6. Hallucinogen

The answer isn't heroin.
The constricted pupils are throwing me off

Ans: clue is nystagmus and pupils - should be Alcohol [PCP causes dilated pupils]

 

[SpecterGT260]

Ans: clue is nystagmus and pupils - should be Alcohol [PCP causes dilated pupils]

You're right, I didn't read carefully. Pcp will also be agitated.

 

[laboholic]

Ans: clue is nystagmus and pupils - should be Alcohol [PCP causes dilated pupils]

Nice. Never thought of alcohol...but it is true.. EtOH and opiates are the only 2 that cause pupil constriction.
What a weird presentation for alcohol toxicity..

 

[res1cue]

Ugh... I'm getting super pissed at this test. postpartum bleeding. Most common cause is atony, right? Except they tell us that the placenta is intact but torn. Do we ignore this info which might point toward uterine inversion (my incorrect answer)? What about retained placenta? Do we just assume they are lying about the intact part? When you throw out a question and you want epidemiology-based answers, don't include unnecessary information... Or how about that picture of, I assume genital herpes, that doesn't have a single herpetic lesion in frame. They are all ulcers. This ambiguous nonsense is just bad test writing.... Although maybe I could argue that some of my school's tests should have prepared me for this...

I put atony, it was correct. Like someone said above, the 2 cm above fundus is the clue

Every resource I have checked says to go to surgery without waiting for further tests IF the US shows decreased flow.

This kid also had abdominal pain and guarding which might change it, but they focused the whole history on his balls and mentioned discoloration of the left hemiscrotum (blue dot sign?)

The issue is that I haven't seen anything that gives a good guideline for when clinical suspicion is enough to not justify a 30 sec US.

actually there was a lot more to this question and it made me think it was an appy. I chose surgical and got it right

For the meningitis pt, did the question stem mention that patient exhibiting any focal neurological deficits? seizures? papiledema? In that case you would do a CT of the head before LP to rule out if the patient has any mass or increase ICP. Otherwise, you could a LP without a CT scan in most other cases.

Yeah there was neurological deficits, new onset

Form 7 was tough. Anyone know the answer to this:
Young guy took some kind of drug. He has constricted pupils, bilat nystagmus, hypertonia.... blank stare, not talking, not reactive to pain.
1. stimulant
2. heroin
3. inhalant
4. PCP
5. Alcohol
6. Hallucinogen

The answer isn't heroin.
The constricted pupils are throwing me off

Answer was PCP, and I don't remember seeing anything about constricted pupils



Took it today, 248, havent taken any other NBME's to compare. Knew this was gonna be a low score one, so took it early so it wouldn't hurt my morale!

One I was confused about was an 18yof, splenomegaly, enlarged virchow's node, what would be elevated? I chose LDH and got it right, but don't know why. Anybody know?

 

[UMN]

I think that was EBV mononucleosis causing autoimmune hemolytic anemia - Increased LDH

 

[res1cue]

That would make sense, but would EBV cause a single enlarged 3cm supraclavicular node?

Also I was thinking EBV at one point and I remember the prompt saying that the girl was completely asymptomatic





Edit: Also I got 2 gyn questions on breast CA wrong

-scaling of nipple + normal mammogram - its not eczema, wouldnt adenocarcinoma of pagets show up on mamogram?

-unilateral yellow nipple discharge + normal mammogram - its not ductal ectasia


could someone help me out here?

 

[SpecterGT260]

I put atony, it was correct. Like someone said above, the 2 cm above fundus is the clue



actually there was a lot more to this question and it made me think it was an appy. I chose surgical and got it right



Yeah there was neurological deficits, new onset



Answer was PCP, and I don't remember seeing anything about constricted pupils



Took it today, 248, havent taken any other NBME's to compare. Knew this was gonna be a low score one, so took it early so it wouldn't hurt my morale!

One I was confused about was an 18yof, splenomegaly, enlarged virchow's node, what would be elevated? I chose LDH and got it right, but don't know why. Anybody know?

Appy wouldn't discolor the scrotum. I thought briefly about incarcerated inguinal hernia but it still didn't fit well.

 

[res1cue]

Appy wouldn't discolor the scrotum. I thought briefly about incarcerated inguinal hernia but it still didn't fit well.

Actually incarcerated inguinal hernia sounds pretty good, and im starting to think that is what it actually was. A lot of SBO symptoms IIRC

Update on my earlier post, I learned that intraductal papillomas tend to be very small and will not show up on mammogram.

 

[laboholic]

Answer was PCP, and I don't remember seeing anything about constricted pupils

"exam shows bilateral nystagmus, constricted pupils, hypertonia..."

I think it was just a bad question

 

[SMT86]

Is this the only thread on CCSSA Form 7? I haven't found any others

I also got a much lower score than I was expecting. I'm glad I'm not alone!

I'm going over my wrong answers, and I'm not sure about a couple of them. Maybe you guys can help me out:

1) Acute gouty arthritis that doesn't respond to celecoxib. Next step in pharmacotherapy is indomethacin?
2) Woman who underwent laparoscopic cholecystectomy presents 7 days later with fever, jaundice and abdominal pain (I assume this is bile duct injury with biliary obstruction). Next step in diagnosis? Medscape mentions CT, HIDA & ERCP as valid options. Which one is preferred?
3) Formication (feeling of insects crawling under skin). Caused by amphetamines?
4) 43-year-old man with pneumonia & small Gram-negative bacilli in sputum. It wasn't Pseudomonas. The only other GNB in the list were E.coli & H.influenzae. Which one, and why?
5) 19-year-old with intermittent watery diarrhea + abdominal cramps & bloating. Most likely cause of diarrhea? Is it decreased bowel motility (IBS)?
6) Claustrophobic patient who has a panic attack during an MRI. "Wishes to resume and complete the test". Next step in management?
7) 20-year-old man with psychotic behavior for the past year + hyperreflexia + resting tremor. Diagnosed with hypothyroidism 6 months ago, now treated with levothyroxine. Normal TSH, normal tox screen. How do you interpret this one? I answered psychotic disorder due to a general medical condition and it was wrong.

Thanks!

 

[123qwe]

Is this the only thread on CCSSA Form 7? I haven't found any others

I also got a much lower score than I was expecting. I'm glad I'm not alone!

I'm going over my wrong answers, and I'm not sure about a couple of them. Maybe you guys can help me out:

1) Acute gouty arthritis that doesn't respond to celecoxib. Next step in pharmacotherapy is indomethacin?
2) Woman who underwent laparoscopic cholecystectomy presents 7 days later with fever, jaundice and abdominal pain (I assume this is bile duct injury with biliary obstruction). Next step in diagnosis? Medscape mentions CT, HIDA & ERCP as valid options. Which one is preferred?
3) Formication (feeling of insects crawling under skin). Caused by amphetamines?
4) 43-year-old man with pneumonia & small Gram-negative bacilli in sputum. It wasn't Pseudomonas. The only other GNB in the list were E.coli & H.influenzae. Which one, and why?
5) 19-year-old with intermittent watery diarrhea + abdominal cramps & bloating. Most likely cause of diarrhea? Is it decreased bowel motility (IBS)?
6) Claustrophobic patient who has a panic attack during an MRI. "Wishes to resume and complete the test". Next step in management?
7) 20-year-old man with psychotic behavior for the past year + hyperreflexia + resting tremor. Diagnosed with hypothyroidism 6 months ago, now treated with levothyroxine. Normal TSH, normal tox screen. How do you interpret this one? I answered psychotic disorder due to a general medical condition and it was wrong.

Thanks!

1- it must have been indo, was not steroids
2- if pt has known stones, hida and ct wont help, but ERCP woud treat since already had a chole
3- ??
4- H flu
5- ??
6- acute panic attack, treat with benzo
7- schizophrenia i think over 1 year, hallucintations and flat affect.

 

[SpecterGT260]

1- it must have been indo, was not steroids
2- if pt has known stones, hida and ct wont help, but ERCP woud treat since already had a chole
3- ??
4- H flu
5- ??
6- acute panic attack, treat with benzo
7- schizophrenia i think over 1 year, hallucintations and flat affect.

HIDA can tell you if there is an obstruction. Some 40% of people have stones and are asymptomatic. IIRC you have to see the pericholic fluid or wall thickening to diagnose it. Ercp is only therapeutic if you have gallstone pancreatitis in which case you would see jaundice and more pancreatic pain (epigastric and whatnot)

 

[123qwe]

HIDA can tell you if there is an obstruction. Some 40% of people have stones and are asymptomatic. IIRC you have to see the pericholic fluid or wall thickening to diagnose it. Ercp is only therapeutic if you have gallstone pancreatitis in which case you would see jaundice and more pancreatic pain (epigastric and whatnot)

I thought there was jaundice, and enough pain to suspect pancreatitis, that was my rationale at least.


anyone comfortable with immuno deficiencies?
4 yo girl with cough and weight loss, no history of serious illness has negative epidermal skin testing for PPD, tetanus, candida, trichophyton, wbc 5100 gastric aspirates have TB in them.
antibody deficiency
complement deficiency
chemtaxis imparied
resp burst impaired
neutropenia
splenic dysfunction
t lymph dysfunction