Official Surgery Shelf Exam Discussion Thread

[filter07]

18 year old man has pain in the right hip and flank after an autoaccident. He is stable. Exam shows eccymosis over the iliac crest, and right flank abraisions. urinalysis shows gross blood. Ct cervical spine is normal. next step? Is the answer "CT of the abdomen" or "Selective renal angiography" and why?

CT abdomen. Angio is invasive and doesn't give you the grade of injury or demonstrate a urine leak. CT with arterial, venous, and delayed phase can give you all the information you need, especially in a stable patient. Most renal injuries are managed nonoperatively.

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[abelabbot]

makes sense. Thanks a lot

 

[abelabbot]

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[VisionaryTics]

content removed by moderator staff

1. acute rejection, which is mediated by cell-mediated immune system (class 2 refers to surface antigens on cells). The first allograft thing is a distractor.

2. This is acute pancreatitis. Patient is tachycardic. They are third-spacing fluid around the inflamed pancreas. Give them some fluid back.

 

[abelabbot]

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[abelabbot]

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[medstudent7860]

^where are these questions from?

 

[abelabbot]

Surgery clinical mastery exam. My bad, I should've made a separate post for these as to not spoil the questions for everyone else. Deleted the questions from here.

 

[Dr.Nick Riviera]

Does anyone know a good resource for whatever obs/gyn appears on this exam? Time is tight as it is, and this doesn't seem to be a subject well represented in a lot of the standard resources. Would the section in step 2 first aid suffice?

 

[Enzymes]

Question from NBME2:

Metabolic acidosis with low bicarb with high NG output, high operative drain output in the abdomen, and high amylase. asked what was the mechanism?

Loss of bicarb from the GI tract?
Loss of bicarb from the kidneys?
Nasogastric suctioning?

Any help with this one?

 

[Bancrofti]

Question from NBME2:

Metabolic acidosis with low bicarb with high NG output, high operative drain output in the abdomen, and high amylase. asked what was the mechanism?

Loss of bicarb from the GI tract?
Loss of bicarb from the kidneys?
Nasogastric suctioning?

Any help with this one?

loss from GI tract

 

[mt10eers2016]

Need some help with these questions from the Surgery practice NBME #2

1. A hospitalized 15-year-old girl has had progressive shortness of breath for 2 hours. She underwent an appendectomy yesterday and has not been out of bed since then. She has had a mild dry cough but no chest pain. Two liters of 0.9% saline have been administered over the past 24 hours. She is alert. Her temperature is 37.7, pulse is 90/min and regular, respirations are 22/min and blood pressure is 105/64. There is no jugular venous distention. Breath sounds are decreased. There is dullness to percussion over the right midlung field with egophony. No wheezes are heard. A grade 3/6 holosystolic murmur is heard best at the left sternal border with radiation to the axilla. There are no gallops. X-rays of the chest are shown. Which of the following is the most likely underlying mechanisms of this patient's shortness of breath?

A. Acute thrombosis of the right pulmonary artery
B. Aspiration of gastric contents during preoperative intubation
C. Collapse of the right middle lobe of the lung from decreased inspiratory effort
D. Postoperative infection with hospital-acquired organisms
E. Severe mitral regurgitation with perioperative volume overload

I picked B and that was wrong

I picked E and that was wrong as well.

Any ideas? I'm thinking that it may be A?

 

[Enzymes]

I picked E and that was wrong as well.

Any ideas? I'm thinking that it may be A?

It's atelectasis C

 

[medstudent7860]

loss from GI tract

Why not NG suctioning? Can someone explain why it's loss from the GI tract?

 

[VisionaryTics]

Why not NG suctioning? Can someone explain why it's loss from the GI tract?

Stomach is full of acid, so predominant NG loss = metabolic alkalosis. With GI losses, you're crapping out bicarb, so you become acidotic.

 

[medstudent7860]

Stomach is full of acid, so predominant NG loss = metabolic alkalosis. With GI losses, you're crapping out bicarb, so you become acidotic.

Thanks! A follow up question to this, since we're talking about acid-base disorders. I understand that CO2 is acid, and bicarb is base, but I'm having trouble understanding the way that the labs are presented in the computer system at my hospital. For example, I had a surgical patient with metabolic acidosis, and we hadn't gotten an ABG on him for awhile, but we were following the "CO2" level that came in the BMP. Since he was acidotic, I would've expected his CO2 to be high and bicarb to be low, but the CO2 levels from the BMP were consistently low, and we watched them trend up to the normal range after we started the patient on IV bicarb, etc. So can someone please explain this to me?

 

[operaman]

Thanks! A follow up question to this, since we're talking about acid-base disorders. I understand that CO2 is acid, and bicarb is base, but I'm having trouble understanding the way that the labs are presented in the computer system at my hospital. For example, I had a surgical patient with metabolic acidosis, and we hadn't gotten an ABG on him for awhile, but we were following the "CO2" level that came in the BMP. Since he was acidotic, I would've expected his CO2 to be high and bicarb to be low, but the CO2 levels from the BMP were consistently low, and we watched them trend up to the normal range after we started the patient on IV bicarb, etc. So can someone please explain this to me?

Just a quirk in how some systems report the labs. Some of them will put HCO3 on the BMP instead of CO2 yet they both mean the same in that context.

I'm sure there's probably a reason for it, but put simply:

CO2 on a BMP = bicarb =~ base
CO2 on an ABG = PCO2 =~ acid (ABGs should also report the bicarb but they usually use HCO3)

 

[Bancrofti]

How do you go about repeating Uworld questions without getting questions you've already seen? I thought we could just reset the question bank as needed, but when I went to the tab it says you only are able to reset in once, and that being only after a 6 month period from subscription start time.

 

[TOUCHDOWNNNNN]

Need some help with these questions from the Surgery practice NBME #2

1. A hospitalized 15-year-old girl has had progressive shortness of breath for 2 hours. She underwent an appendectomy yesterday and has not been out of bed since then. She has had a mild dry cough but no chest pain. Two liters of 0.9% saline have been administered over the past 24 hours. She is alert. Her temperature is 37.7, pulse is 90/min and regular, respirations are 22/min and blood pressure is 105/64. There is no jugular venous distention. Breath sounds are decreased. There is dullness to percussion over the right midlung field with egophony. No wheezes are heard. A grade 3/6 holosystolic murmur is heard best at the left sternal border with radiation to the axilla. There are no gallops. X-rays of the chest are shown. Which of the following is the most likely underlying mechanisms of this patient's shortness of breath?

A. Acute thrombosis of the right pulmonary artery
B. Aspiration of gastric contents during preoperative intubation
C. Collapse of the right middle lobe of the lung from decreased inspiratory effort
D. Postoperative infection with hospital-acquired organisms
E. Severe mitral regurgitation with perioperative volume overload

I picked B and that was wrong

2. A previously healthy 42-year-old man comes to the physician because of a 2 day history of right knee pain and an inability to extend the right knee. The symptoms began when he was getting up from a low chair. His temperature is 98.6. Examination of the knee shows tenderness to palpation over the medial joint line and a joint effusion. Ligament stability is normal. Range of motion is from 15 to 100 degrees. An x-ray of the knee shows no abnormalities. Which of the following is the most likely diagnosis?

A. ACL injury
B. Bursitis
C. Chondromalacia
D. Collateral ligament injury
E. Patella dislocation
F. Patellar tendon rupture
G. Posterior cruciate ligament injury
H. Torn meninscus

I picked B, that was wrong

Thank you for the help!

I need help with the same questions. Were you able to find the correct answers?

If anyone else can help with these questions, that'd be awesome! Thanks in advance!!

 

[zany_brainy]

How do you go about repeating Uworld questions without getting questions you've already seen? I thought we could just reset the question bank as needed, but when I went to the tab it says you only are able to reset in once, and that being only after a 6 month period from subscription start time.

The best way would probably be marking all of the surgery questions, then selecting the marked surgery questions to create a test.

 

[sjonies88]

I'll be starting my surgery rotation next week and am trying to gather my resources prior to the start of the rotation. I've gone through this thread to get a feel for what people think are useful resources but I know I will be busier than I initially planned for on this rotation due to due to unexpected illness in a family member. That begin said, I won't be able to use as my resources as I'd like to and am trying to streamline my studying. Given my likely major time crunch - and knowing that I'm okay with getting a 'pass' for this rotation instead of an honors because I know with the family illness, there's already a lot on our plates at this time - would using only Pestana's book and the surgery-specific UWorld questions suffice for passing the shelf? I had medicine a few months ago, scored in the mid80s on that shelf using MKSAP primarily, if that helps add context...

 

[operaman]

content removed by moderation staff

As above.

 

[turboE36]

^Thank you very much sir. You rock.

 

[turboE36]

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[Ismet]

This thread has been reopened.

Before posting, please review the sticky at the top of the Clinical Rotations forum pertaining to copyrighted materials.

1. Do not copy/paste questions from NMBE, UWorld, or any other copyrighted material. You may paraphrase a question in order to ask a question about it, but it should not bear resemblance to the actual question.

2. Do not request copyrighted materials in this thread or via PM. There have been at least 5 warnings in this thread telling members not to ask for Pestana audio/pdf or pdfs of other resources. Pestana is copyrighted material, and requesting this is against TOS and counts as a copyright violation.

Posting copyrighted material, in addition to being illegal, is against SDN TOS, and doing so may result in probation, posting restriction, or banning.

 

[medstudent7860]

I have a question. So I thought that the surgery shelf was very hard/specific. Will the surgery questions on Step 2 be similar? Will it be that specific? I also thought that UWorld was a poor representation of what was on the surgery shelf. Are the UWorld surgery questions more similar to the Step 2 surgery questions or is the shelf exam?

 

[operaman]

I have a question. So I thought that the surgery shelf was very hard/specific. Will the surgery questions on Step 2 be similar? Will it be that specific? I also thought that UWorld was a poor representation of what was on the surgery shelf. Are the UWorld surgery questions more similar to the Step 2 surgery questions or is the shelf exam?

Much of this will depend on the particular draw of questions you get. My feeling was that the CK surgery questions were pretty easy compared to the shelf, but Surg was my first shelf and my impression may have been colored by that experience. The CK questions are definitely more like NBME in that they inevitably make you contend with ambiguity in a way that World does not. World questions are beautifully written with the intent of teaching the material; CK and Shelves are written to assess your clinical thinking. This is a subtle but important distinction and the reason it's good to practice with NBME materials as your exam approaches.

I know it's a cop out answer, but overall CK covers content more like World, but requires thinking more like the NBMEs. You will inevitably feel ambiguous about many of the questions.

 

[Apoplexy__]

Could use a hand with an NBME 1 question: Was the guy with the chronic ileofemoral thrombus supposed to get thrombolysis?

 

[Apoplexy__]

Also, some NBME 2 Q's:

-Woman has obstructive jaundice + RUQ pain for a week, after a lap chole months ago. Answer isn't postoperative bile leak...what could it possibly be?
-Guy is bleeding out. What finding best indicates adequate resuscitation? Answer isn't pulse, is it urine output?
-Man is about to have AAA surgery, with minimal medical history. What study is most appropriate to predict risk of perioperative MI?

 

[VisionaryTics]

Also, some NBME 2 Q's:

-Woman has obstructive jaundice + RUQ pain for a week, after a lap chole months ago. Answer isn't postoperative bile leak...what could it possibly be?
-Guy is bleeding out. What finding best indicates adequate resuscitation? Answer isn't pulse, is it urine output?
-Man is about to have AAA surgery, with minimal medical history. What study is most appropriate to predict risk of perioperative MI?

Probs retained stone in CBD/Mirrizi's. ERCP/MRCP.

UOP. Key for resuscitation is stick a foley in, follow UOP. Remember, you're not givings fluids to lower the pulse, you're giving fluids to restore end-organ perfusion. The bedside signs of end organ perfusion are UOP and mental status.

Stress test?

 

[Apoplexy__]

Probs retained stone in CBD/Mirrizi's. ERCP/MRCP.

UOP. Key for resuscitation is stick a foley in, follow UOP. Remember, you're not givings fluids to lower the pulse, you're giving fluids to restore end-organ perfusion. The bedside signs of end organ perfusion are UOP and mental status.

Stress test?

Thanks a lot! Regarding your answers...

1. That fits with an answer choice. So postop bile leak is not associated with obstructive lab values or jaundice, and that's how you know, right?
2. Great!
3. Would a stress test be more fitting than an echo or coronary angio? Is a stress test kind of the standard thing you do?

 

[VisionaryTics]

Thanks a lot! Regarding your answers...

1. That fits with an answer choice. So postop bile leak is not associated with obstructive lab values or jaundice, and that's how you know, right?
2. Great!
3. Would a stress test be more fitting than an echo or coronary angio? Is a stress test kind of the standard thing you do?

1. Correct. Fever, pain, leukocytosis, transaminitis. There's usually no true obstruction.
2.
3. Stress test looks for functional heart disease (how strong is this heart? can it take stress of anesthesia and surgery?) Echo can give you EF, but doesn't tell you anything about how heart will do when stressed (unless you get a stress echo). If patient has an abnormal stress test, they will go for cath. Cath is not a screening test.

 

[Apoplexy__]

1. Correct. Fever, pain, leukocytosis, transaminitis. There's usually no true obstruction.
2.
3. Stress test looks for functional heart disease (how strong is this heart? can it take stress of anesthesia and surgery?) Echo can give you EF, but doesn't tell you anything about how heart will do when stressed (unless you get a stress echo). If patient has an abnormal stress test, they will go for cath. Cath is not a screening test.

Fantastic. Thanks so much.

 

[pancrease]

Posting since I appreciated hearing everyone else's strategies and experiences:
- I went through Pretest Surgery and Case Files 1x each, and took notes on the high-yield points which I reviewed in the 2-3 days leading up to the shelf.
- Also watched the UT High-Yield Surgery lecture 1 week before the shelf - highly recommend (http://som.uthscsa.edu/StudentAffairs/thirdyear.asp).
- Read through the Pestana PDF (not the book) 1x, not sure it helped all that much.
- Ended up with a 96

 

[Pericyclic]

Thought I'd contribute, recently took and waiting for score . Its tough but doable, pretty line with most other shelfs imo.

I didn't feel that not taking medicine before precludes you from doing well. This was my second to last shelf and I didn't have medicine and I'm not really sure if medicine would have helped me get the questions I got wrong. Did 8 weeks of straight general surgery with mostly bread and butter.

I used:
Pestana little book with questions x many many times
Uworld Surgery + GI+ Fluids ; repeat missed
Pretest Surgery x1
Casefiles x1
Gave up on NMS casebook 5 pages in
NBME 1+2


- There are a handful of very random either not related to surgery at all or a question that would require hyperspecialization in a surgical field to know ; you either somehow know it or you don't .
- Pestana by far is the best resource hands down. 40% of the test is predictable general surgery questions many are in pestana.
- Lots of GI workup, i.e. people with dysphagia or belly pain or blood out of a orifice . This is where medicine helps but easily can be tackled by doing uworld GI questions. I felt the fluid questions wern't really tested
- Good amount of neurology (not really neurosurgery) with smattering of ortho and vascular
- Know the different types of shock well, and identifying pnuemo vs tamponade vs hypovolemia . This is just basic stuff important to surgery in general also
- Biggest thing is knowing when to bring someone in for a ex-lap or when to observe/ work them up more. This question is asked many many times
- Dont underestimate peds. Things like heart murmurs, or pediatric GI emergencies are all fair game.
- I think theres a lot of hype around NMS. Its good for getting the basic workup of a Gen surg problem and giving you a good overview but many of the things emphasized are nitty gritty - the shelf felt very much big picture things.
- I felt NBMEs reflected the kind of questions they ask both in randomness, but also how they will put two veryp ossible answers as choices.

best of luck, read when you can!

 

[medicalstadent]

I just posted about this in another thread but thought I would contribute here too

I used deVirgilio's Surgery: A Case Based Clinical Review (its on amazon for around 55$). It has about 50 or so chapters and 300 questions in the back. In my opinion, it is all you need to kill the shelf. I scored > 90%. I plan on going into surgery. There were several times on my shelf exam where I got a question right because I had a similar question from that book. I heard about it from my friend going to med school at UCLA. Apparently their surgical chairman wrote it and it is the book they all use there.

Also, I agree with above poster - dont underestimate peds, i had a lot of trauma and peds on my shelf

 

[Elixir6]

Thought I'd contribute. Definitely disagree that this was a "medicine" shelf. I think just because a question doesn't specifically deal with cutting that it isn't in the relm of a surgeon's daily work. Did none of you people saying it's a medicine shelf do outpatient, consult on patients or take care of patients pre-op and post-op?

Many of the questions did deal with situations that could be dealt with surgically. However, the decision is to know when cutting is indicated, and what the diagnostic and management steps might be for the work up before getting to surgery. Often, the patient is presented at a state well before an operation is indicated - for instance, early in the work-up of GI bleeding, or for an endocrine disorder.

That being said I think having medicine first would be a big advantage... which I did not have. Things like acid-base/electrolytes were there. I found many of the questions to be incredibly easy - at least 30-40 questions were give-me's. About 15-20 tough questions. The others intermediate. About 25-30% of the questions were trauma - definitely the most high yield topics. The disdain of surgeons for OBGYNs was clearly evident as there were 3-4 questions in which an OBGYN patient has a post-op complication (of course implying ineptitude of the OBGYN - hardly fair, but that's what it was. Surgeons have such fragile self images and their egos need constant stroking).

Many of the topics were covered by Pestana and I thought it was the best resource, however, after taking the shelf, I feel like it would not have helped me on the shelf if I had Pestana memorized with photographic memory to answer the toughies. Not sure what resource would help with those. There were even some "Step 1"-like questions about bugs and stuff that I have no idea what resource would have prep'd you.

I read NMS Casebook 2x. After reading many times in this thread how great that would be, I was disappointed because I felt this book did not add anything that wasn't in Pestana. Maybe only good for the pre-op and post-op chapters.

I did okay with an 86... not sure what percentile that is

Pestana 2-3X
USMLEWorld
NMS Casebook 2X <- not as good as everyone said
Pestana audio <- also very good, but not necessarily "high yield"

I got FirstAid for Surgery from a friend who gave it to me for free, but did not read it. I think the only ways for me to have done better would have been if there were more USMLEWorld questions for surgery and if I had medicine first. Don't ignore topics such as optho, ENT, urology etc... There were a couple of ethics Qs that you can't prepare for, so hopefully you have good judgement, as they were pretty easy.

'lixir

 

[1dayatatime]

Some q's from nbme 1 that i paraphrased and want answers/help with , please.

30 yo guy with painless and progressively enlarging testicle with no nodule and no transillum.
a. testic tumor
b. spermatcele
c. indirect hernia

22 yo man GSW to r calf. Vitals are stable at presentation. entrance wound over medial part of posterior calf and no exit wound. calf is tense and painful. Passive movt of great toe exacerbates pain. Pulses are norml. Cap refill is 2 secs. NOrmal sensation. XR shows the bullet in the medial part of the posterior calf. WHich is the most appropriate step in mgmt?
a. MRI of calf
b. irrigation
c. femoral arteriography
d. surgical decompression

I picked c but that was wrong. I thought we had to see the vessels but I'm now thinking it's compartment syndrome? -- thus d? Or is it Irrigate b/c there's no major vessels in the medial posterior calf?

4 days after CABG, man has severe sudden pain in big toe. Had CP with exertion 10 days ago and was admitted to hospital, given ASA and hep for 3 days. Cardiac Cath showed 3 vessel dx. Uncomplicated procedure and post-op course. Vitals nml. New bruises over trunk and extremities (both UE and LE). Surgical site c/d/i. Labs show 12,000 WBC's, 8000 platelets, INR of 1/PT and PTT both wnl. What is the diagnosis?
a. cholest embol syndrome --> wrong
b. DIC
c. gout
d.HIT
e. ITP --> is this right? why...

62 yo f with 3 weeks of progressive SOB, pain in R chest wall, nonprod cough and weight loss in past 3 months. Had R breast CA 6 yr ago tx'd with lumpectomy and XRT and chemo. Appears cachetic. RR 20/min, o2 sat of 90% at RA. TTP over R chest. Breath sounds decreased on R with dullness to percussion. Friction rub heard. Nml heart sounds. What is the most likely diagnosis?
a. chest wall recurrence? (is this right? how would this cause a friction rub?)
c. pericardial effusion
e. malignant pleural effusion

47 yo Dude with 2 days of Fever and increasing rectal pain. Has T2DM. Vitals (fever to 102 and bp 130/80). Tender mass at anal verge on 1 side. Hb is 9.6, Wbc 18K, glu is 350. Which is the most appropriate next step in mgmt?
b. CT Abd and Pelvis (i picked this, it was wrong. I thought we had to see either how deep this perirectal abscess went or if there was a mass to explain his Hb)
c. Flagyl
d. flex sig
e. I and D (is this right?)

4 days of progressive back pain and weak/numb legs, no urination for 12 hrs. Had mastectomy 5 yrs ago. CN's intact. Muscle strength nml in UE and decreased in LE's diffusely. DTR's hyperreflesive in knees and ankles. Babinski skin + b/l. Sensation to pinprick decrased below T4 and absent vibratory sensation in LE's. Unable to walk. 400 cc of urine obtained from insertion of catheter. Whats the location of the abnormality?
a. cauda equina
b. cerebral hemispheres
c. lumbar spinal cord
d. medulla
h. thalamus
i. thoracic spinal cord

 

[Winged Scapula]

No time today for all of these but let's work through a few:

Some q's from nbme 1 that i paraphrased and want answers/help with , please.

22 yo man GSW to r calf. Vitals are stable at presentation. entrance wound over medial part of posterior calf and no exit wound. calf is tense and painful. Passive movt of great toe exacerbates pain. Pulses are norml. Cap refill is 2 secs. NOrmal sensation. XR shows the bullet in the medial part of the posterior calf. WHich is the most appropriate step in mgmt?
a. MRI of calf
b. irrigation
c. femoral arteriography
d. surgical decompression

I picked c but that was wrong. I thought we had to see the vessels but I'm now thinking it's compartment syndrome? -- thus d? Or is it Irrigate b/c there's no major vessels in the medial posterior calf?

Young male, likely to have considerable muscle mass in his lower extremity. Pain with passive or minor movement is the hallmark of an acute compartment syndrome (ACS)in an extremity. The lower leg is a common site for ACS. He has pain with movement of the GT, likely with plantar movement. Which compartment contains the muscles for plantar flexion? Which compartment contains the bullet?

So of your choices:
- MRI; what's this going to tell you? Not much that will change management; not all bullets are MRI compatible.
- Irrigation: nothing wrong with washing out the wound but that's not going to fix his symptoms
- Femoral Ateriography: does he have any hard signs (or even soft) of major vascular injury? Are there major vessels in the medial aspect of the lower leg?

Answer is?

4 days after CABG, man has severe sudden pain in big toe. Had CP with exertion 10 days ago and was admitted to hospital, given ASA and hep for 3 days. Cardiac Cath showed 3 vessel dx. Uncomplicated procedure and post-op course. Vitals nml. New bruises over trunk and extremities (both UE and LE). Surgical site c/d/i. Labs show 12,000 WBC's, 8000 platelets, INR of 1/PT and PTT both wnl. What is the diagnosis?
a. cholest embol syndrome --> wrong
b. DIC
c. gout
d.HIT
e. ITP --> is this right? why...

First: Is it supposed to be 8,000 PLT or 80,000?

Does he any any risk factors for ITP? Probably not but let's not rule that out just yet. How does ITP manifest itself? He does have thrombocytopenia. He does have new eccymotic areas. Does he have any symptoms not consistent with ITP?

What do you know about HIT? Its a favorite surgical board question. Can it occur after 3 days of heparin use? What are the lab and physiologic changes seen with it?

DIC? PT/PTT are usually abnormal but may not be. They haven't really given you enough information to rule this in or out based on lab findings.

62 yo f with 3 weeks of progressive SOB, pain in R chest wall, nonprod cough and weight loss in past 3 months. Had R breast CA 6 yr ago tx'd with lumpectomy and XRT and chemo. Appears cachetic. RR 20/min, o2 sat of 90% at RA. TTP over R chest. Breath sounds decreased on R with dullness to percussion. Friction rub heard. Nml heart sounds. What is the most likely diagnosis?
a. chest wall recurrence? (is this right? how would this cause a friction rub?)
c. pericardial effusion
e. malignant pleural effusion

As you correctly note, chest wall recurrence is not going to give her the symptoms above. So let's rule that one out right away.

A patient with a prior history of malignancy (significant enough to need chemotherapy, so we're going to assume, 6 years ago prior to the days of the Oncotype, that she was node positive) who is now cachectic: you have to assume recurrent disease as your first priority.

Do any of the signs point to pericardial effusion? You didn't say whether this was a pericardial or pleural friction rub but I"ll assume the latter. Normal heart sounds? If she had a substantial effusion, you'd expect some changes but otherwise even with a moderate size pericardial effusion you can maintain normal heart sounds.

So what seems most likely? Patient with a malignancy 6 years ago, now with shortness of breath, cachexia, reduced breath sounds, friction rub, etc etc. Sounds like Choice e to me.

47 yo Dude with 2 days of Fever and increasing rectal pain. Has T2DM. Vitals (fever to 102 and bp 130/80). Tender mass at anal verge on 1 side. Hb is 9.6, Wbc 18K, glu is 350. Which is the most appropriate next step in mgmt?
b. CT Abd and Pelvis (i picked this, it was wrong. I thought we had to see either how deep this perirectal abscess went or if there was a mass to explain his Hb)
c. Flagyl
d. flex sig
e. I and D (is this right?)

Ok you've got a diabetic who's febrile and with a visible perirectal mass. How does a CT scan change your management (and are you sure the Hb is 9.6 or was that his HgA1c)? Antibiotics might be reasonable but they aren't your next step; even if they were is Flagyl the appropriate choice? This guy's sick, you need to do something to make that better.

 

[1dayatatime]

BIG THANKS to Winged Scapula! You were very helpful I put my new comments in RED

First: Is it supposed to be 8,000 PLT or 80,000? Platelets are 8000

Does he any any risk factors for ITP? Do you just mean young female or young child? I don't know any other risk factors...
Probably not but let's not rule that out just yet. How does ITP manifest itself? He does have thrombocytopenia. He does have new eccymotic areas. Does he have any symptoms not consistent with ITP? I just didn't think he fit the standard pic of ITP but I guess cholest emboli wouldn't cause bruisng in BOTH UE and LE right? (just 1 extremity and usually unilateral?)

What do you know about HIT? Its a favorite surgical board question. Can it occur after 3 days of heparin use? What are the lab and physiologic changes seen with it? I gotta look this up since I don't know of the top of my head

DIC? PT/PTT are usually abnormal but may not be. They haven't really given you enough information to rule this in or out based on lab findings.



As you correctly note, chest wall recurrence is not going to give her the symptoms above. So let's rule that one out right away.

A patient with a prior history of malignancy (significant enough to need chemotherapy, so we're going to assume, 6 years ago prior to the days of the Oncotype, that she was node positive) who is now cachectic: you have to assume recurrent disease as your first priority.

Do any of the signs point to pericardial effusion? You didn't say whether this was a pericardial or pleural friction rub but I"ll assume the latter. The question just said "friction rub heard on Right". I leaned toward pericardial friction rub but now i'm thinking I should've thought pleural instead since there were normal heart sounds. I guess I just associate "friction rub" with pericarditis. I guess you can have a "friction rub" from pleuritis? Normal heart sounds? If she had a substantial effusion, you'd expect some changes but otherwise even with a moderate size pericardial effusion you can maintain normal heart sounds.

So what seems most likely? Patient with a malignancy 6 years ago, now with shortness of breath, cachexia, reduced breath sounds, friction rub, etc etc. Sounds like Choice e to me.



Ok you've got a diabetic who's febrile and with a visible perirectal mass. How does a CT scan change your management (and are you sure the Hb is 9.6 or was that his HgA1c)? Def. was his Hb, not A1c. Antibiotics might be reasonable but they aren't your next step; even if they were is Flagyl the appropriate choice? I was taught Metronidazole is good for rectal issues. At my hospital, we add that to everyone with a rectal issue. This guy's sick, you need to do something to make that better.

 

[Winged Scapula]

@1dayatatime - unfortunately, the way you responded makes it difficult for me to reply. For future reference:

1) click +Quote
2) Insert Quote
3) Respond

If you wish to respond *within* the quote, insert [/quote] (type it exactly like that) at the end of the user's statement and then type your reply.


Ok, now that that's squared away: I get to ask the questions!

For scenario number 1, yes I meant that he does not fit the typical picture of ITP. ITP is *usually* chronic in adults, right? But that doesn't mean that it can't be the answer. When someone has ITP was is the classic skin presentation? Is it bruising or is it petechiae? My point is that you need to ask yourself about what are the common things (although admittedly exams like to ask about things you never see in real life).

You should read about heparin induced thrombocytopenia because it is a common presentation on surgical exams and you may see it in practice (even non- surgical patients are on heparin/LMWH).

Yes, you can have a friction rub from pleural diseases; mostly commonly referred to as a pleural rub.

Lastly, there's nothing wrong with Flagyl. Why is it added to "everyone" with a "rectal issue" at your hospital? What does it cover? My point is however in the scenario presented, you've described a pretty sick patient. Flagyl is not sufficient antibiotic coverage (don't most patients at your hospital get "double coverage" or "broad spectrum" antibiotics? Have you heard those terms before?) and more importantly, treating a sick patient with antibiotics alone is not adequate.

 

[1dayatatime]

Hmm, for some reason when I hit "quote" it wanted me to drag which ones to quote and on my little tiny laptop it wouldn't drag but alas I hope I can figure it out next time - thanks! EDIT: I just saw my post and clearly failed at this again lol sorry!

@1dayatatime - unfortunately, the way you responded makes it difficult for me to reply. For future reference:

1) click +Quote
2) Insert Quote
3) Respond

If you wish to respond *within* the quote, insert

(type it exactly like that) at the end of the user's statement and then type your reply.


Ok, now that that's squared away: I get to ask the questions!

For scenario number 1, yes I meant that he does not fit the typical picture of ITP. ITP is *usually* chronic in adults, right? But that doesn't mean that it can't be the answer. When someone has ITP was is the classic skin presentation? Is it bruising or is it petechiae? My point is that you need to ask yourself about what are the common things (although admittedly exams like to ask about things you never see in real life). [/quote] You're right. Bruising is odd for ITP. Is the answer HIT then? I read that there's two types. You can have HIT w/i a day if you have had Hep w/i the past 3 months, or you can have HIT w/i 5-14 days if it's your first time exposed to Hep. So...3 days doesn't really make sense either since it doesn't say he had a previous exposure to Hep Now i'm really confused what the answer is.

You should read about heparin induced thrombocytopenia because it is a common presentation on surgical exams and you may see it in practice (even non- surgical patients are on heparin/LMWH).

Yes, you can have a friction rub from pleural diseases; mostly commonly referred to as a pleural rub.

Lastly, there's nothing wrong with Flagyl. Why is it added to "everyone" with a "rectal issue" at your hospital? What does it cover? My point is however in the scenario presented, you've described a pretty sick patient. Flagyl is not sufficient antibiotic coverage (don't most patients at your hospital get "double coverage" or "broad spectrum" antibiotics? Have you heard those terms before?) and more importantly, treating a sick patient with antibiotics alone is not adequate.[/QUOTE]
I've heard of "broad spec" but is that the same as "dbl coverage"? I'm guessing that means gram + and gram - or anaerobes. I see why I&D is a good answer, but why the low Hb in a 50+ yr old patient?

 

[Winged Scapula]

Hmm, for some reason when I hit "quote" it wanted me to drag which ones to quote and on my little tiny laptop it wouldn't drag but alas I hope I can figure it out next time - thanks! EDIT: I just saw my post and clearly failed at this again lol sorry!

That's ok - you'll figure it out.

You're right. Bruising is odd for ITP. Is the answer HIT then? I read that there's two types. You can have HIT w/i a day if you have had Hep w/i the past 3 months, or you can have HIT w/i 5-14 days if it's your first time exposed to Hep. So...3 days doesn't really make sense either since it doesn't say he had a previous exposure to Hep Now i'm really confused what the answer is.

The way I read the question is that he received ASA and Heparin for 3 days, got a cardiac cath and then a CABG. I can assure you if that was the case he received more than 3 days total of heparin. But I agree its not clear.

I see why I&D is a good answer, but why the low Hb in a 50+ yr old patient?

It appears that you're assuming that acute blood loss is the cause; have you considered the hematologic consequences of sepsis or chronic illness?

 

[1dayatatime]

Hmm, I know you can have hypotension with sepsis but low Hb? I thought Hb took days to change...
@Winged Scapula
You da best! Thanks again!

 

[Winged Scapula]

Hmm, I know you can have hypotension with sepsis but low Hb? I thought Hb took days to change...
@Winged Scapula
You da best! Thanks again!

Yes you can have a low Hg with sepsis, although this is generally seen more commonly in the critically ill.

The finding is unusual and may be related to sepsis, it may be related to chronic illness (why does he have an abscess? What diseases may predispose to that?), he may have a chronic blood loss or issue with hematopoiesis. It may be that the question is poorly written and it has nothing to do with the issue at hand.

 

[VisionaryTics]

Options are lame. Next option should be to do an awake fiber-optic intubation. Doing a trach on an awake patient with an irradiated neck and a tumor recurrence is not gonna happen, and I wouldn't want to put this guy to sleep. I wonder if the answer is to bronch him, to better characterize the lesion, but I don't think that should be your next step either.

Someone recently liked my post so it brings up this old argument. I remember getting some flack.

In my mind, now, patient comes in with unintubatable airway which is scary (infection, tumor, trauma, etc), awake trach. The hardest part is getting an attending to come in.

It's not a slash cric. You can take your time and work down to the airway with good local. Yeah, we do a ton of these on post-radiation necks. Just go slow, talk to your patient, and be safe. They work.

 

[1dayatatime]

1 q from NBME 2 that I am unsure about:
2 days PO from L CEA carotid endarterectomy, dude has slurred speech and weakness or R arm and Leg for 1 hour. On d/c yesterday he had a mild L sided earache but neuro exam was wnl. Takes ASA QD. Appears anxious and diaphoretic. BP is 170/95. C/d/i L neck incision w/o swelling. CN's grossly intact. Muscle strenght is 2/5 on R and 5/5 on L. Cannot name simple objects. Carotid duplex shows no abnormalities and CT head shows intraparenchymal hemorrhage. This compliclation is most likely a result of:
a. carotid thrombosis (what i picked, but i guess it doesn't make sense anyways b/c it would be a carotid EMBOLUS)
b. HTN (plausible? his BP is high and HTN is a cause of intraparenchymal hem. in FA for step 1)
c. intracranial aneurysm (this appears to be the right answer according to previous posts, I kinda get it but isn't this from a berry aneurysm? what does this have to do with CEA?)
e. platelet dysfxn (i guess i'm also iffy on the whole anti-platelet vs anti-coag thing. He was on ASA after all)

Thanks in advance!

 

[imymemine]

another study regimen that resulted in a 99 scaled score, in the order i did them:
1) pestana (little green book), text and questions
2) all uworld surgery questions
3) all pretest questions
all in the last week before test:
4) all of case files
5) read pestana again, text only
6) re-did uworld surgery questions i missed
7) re-did ~50% of the pretest questions i missed (would have done all but ran out of time)

other advice tidbits:
- i had surgery after OB/GYN, IM, and peds and i do think this was an advantage
- several questions about diabetic vs. venous insufficiency vs. arterial occlusion foot ulcers - know how to tell which one is which and the treatment for each. seriously, know this cold.
- quite a few gyn surg questions that i don't think were covered in the sources above. if you haven't had obgyn yet it would be a good idea to review ovarian tumors, PID/TOA, ovarian torsion, ovarian cysts, ectopic preg (diagnosis & treatment), since these are all things on the ddx for abdominal pain or masses
- zero questions on specific staging of tumors. my attending said this was "fair game for the shelf" but studying specific TNM and stage crap is a waste of time. just know the general principles for breast, colon, sarcomas, and melanoma - where they metastasize and when to do surgery, when to do lymph node biopsy
- as usual there were a few wtf questions that no amount of studying would have prepared me for... don't waste time worrying about them

 

[blahblah56]

POD5 s/p I&D of inguinal sebaceous cyst, 57 yo male with 8 hr history of scrotal pain. PMH of DM2, CAD, hypercholesterolemia. Temp 102, HR 120, BP 90/50. PE shows scrotal edema and tenderness at base, 3cm black surgical incision with erythema extending to incision site. WMC 21k, 7% bands, Na 130, K 3.4, Glu 324. You give NS and insulin, whats the next best step?

a. warm compress
b hyperbaric O2
c. IV antifungal
d. IV K
e. surgical debridement

Obviously this is a surgery shelf and were looking at fourniers so debridement is the answer, but given the low K, wouldnt you want to give K with the insulin to prevent worsening of the hypokalemia?

 

[Psai]

listened to pestana audio twice, read pestana twice with questions the second time, nms surgery casebook 1.5x, uworld questions x2, pretest
got like half of pretest wrong but i thought it was decent for learning
pestana is gold
also knowing about the thyroid was important for some reason
mid 80s on shelf