Official Surgery Shelf Exam Discussion Thread

[psylocke]

Have those who done NMS Surgery Casebook found it helpful for the NBME? I gave it one pass and not sure if it's worth a second...

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[Trogdor_The_Burninator]

Have those who done NMS Surgery Casebook found it helpful for the NBME? I gave it one pass and not sure if it's worth a second...

I thought it was helpful. I wouldn't say it can be used as a sole resource as there isn't much in it on pathophysiology (which does get tested on the shelf), but the NMS casebook offers a good framework on how to approach a work-up for a certain problem and/or how to organize a list of differential diagnoses. But whether you should read it (or notes/highlights from it) again depends on how close to the shelf you are. You may be better served with other resources if the exam date is closing in.

 

[psylocke]

I thought it was helpful. I wouldn't say it can be used as a sole resource as there isn't much in it on pathophysiology (which does get tested on the shelf), but the NMS casebook offers a good framework on how to approach a work-up for a certain problem and/or how to organize a list of differential diagnoses. But whether you should read it (or notes/highlights from it) again depends on how close to the shelf you are. You may be better served with other resources if the exam date is closing in.

Thank you for your input! I'm currently a week away from my shelf. I'll devote the rest of my time to reviewing Pre-test and reading Pestana's Surgery Notes. Hopefully I'll have time to fit in Form 3 and 4 as well.

 

[fulminantgangrene]

Surgery shelf at the end of this month. Haven't had IM. What should I study? I've gone through Pestana and questions, UWORLD surgery, some of UWORLD medicine (GI, fluids/renal, endocrine, heme, ENT, ophthalmology), Devirgilio all 1x. My NBME scores have not been good (70s). I could definitely revisit some resources and review, but are there any high yield resources that I am missing? Should I be doing more IM topics in UWORLD, such as cardiology/pulmonology? Any one have some more updated thoughts on how Pretest Surgery was?

 

[seminoma]

Answers to some in quote. Anyone have any idea on the jaundice question? Thanks!

Jaundice one is overproduction of bili. Patient got 10 units and now has a mixed hyperbili (2.3 Dbili, 2.7indirect bili). Liver is putting out tons of dbili leading to overflow into circulation (high Dbili) and at the same time is being overwhelmed by increased hemolysis of those 10 units of pRBCs (high indirect).

You know there's no issues with the liver because GGT is normal. You also know there's no biliary obstruction because alk phos is normal.

Form 3 question:

What is the best imaging method to screen for cervical trauma? Patient is s/p MVC with facial lacerations, HR 120 BP 100/70 (this is the only information provided in the q).
-- A: CT
-- B: lateral x-ray
-- C: MRI
-- D: myelography
-- E: tomography

CT is incorrect. I know xray is preferred if no other major trauma needs to be evaluated (per UTD) but presence of facial lacerations makes me want a CT. It also doesn't specify if there are concerns for any other chest/abdomen injuries, in which case I would also get a CT.

It's lateral xray. Patient is tachy and borderline hypotensive. Xray them in the trauma bay with option to go to CT once they're for sure stabilized. Also, FYI classic teaching is that lateral xray is "best" for cervical spine injuries, however in the more modern world with rapid CT (and more widely available CT), the use of CT is becoming more common. I think that tidbit is in Pestana or NMS casebook.

Abscess is correct for the first one and I also agree with no primary closure for human bites.

Except on the face.

 

[seminoma]

NBME 3:
60 F, dysphagia x3 mos. 10 year hx heartburn. Unremarkable physical exam. Barium swallow shows 2 cm tapered esophageal stricture with moderate dilatation of proximal esophagus, Most appropriate initial step in mgmt?
A) hydrostatic balloon dilatation (no)
B) endoscopic placement of siastic feeding tube
C) esophagoscopy and biopsy
D) antireflux operation (would this be the answer? fundoplication?)
E) esophageal resection

C. Need to be sure it's benign before you treat it. She's old-ish, has 10yr h/o heartburn, which is probably undiagnosed GERD given her pretty new dysphagia and stricture. Gotta check for cancer.

 

[byaaaaaaah23]

Jaundice one is overproduction of bili. Patient got 10 units and now has a mixed hyperbili (2.3 Dbili, 2.7indirect bili). Liver is putting out tons of dbili leading to overflow into circulation (high Dbili) and at the same time is being overwhelmed by increased hemolysis of those 10 units of pRBCs (high indirect).

You know there's no issues with the liver because GGT is normal. You also know there's no biliary obstruction because alk phos is normal.



It's lateral xray. Patient is tachy and borderline hypotensive. Xray them in the trauma bay with option to go to CT once they're for sure stabilized. Also, FYI classic teaching is that lateral xray is "best" for cervical spine injuries, however in the more modern world with rapid CT (and more widely available CT), the use of CT is becoming more common. I think that tidbit is in Pestana or NMS casebook.



Except on the face.

Thanks @seminoma. I thought the timing was a little off for overproduction of bili but I guess I'm not sure how long it takes for conjugation to occur. I did think hemolysis would closer to the transfusion though-- any thoughts?

 

[seminoma]

Thanks @seminoma. I thought the timing was a little off for overproduction of bili but I guess I'm not sure how long it takes for conjugation to occur. I did think hemolysis would closer to the transfusion though-- any thoughts?

Honestly I don't know anything about the timeline. To be clear, I don't think this is a transfusion reaction. I think it's just a physiologic response to a large bolus of RBCs in a patient who likely has some renal dysfunction following trauma, hypotension, and surgery. In addition, all other answers seem incorrect based on the normal GGT and alk phos.

 

[dfib slim]

Thanks @seminoma. I thought the timing was a little off for overproduction of bili but I guess I'm not sure how long it takes for conjugation to occur. I did think hemolysis would closer to the transfusion though-- any thoughts?

Honestly I don't know anything about the timeline. To be clear, I don't think this is a transfusion reaction. I think it's just a physiologic response to a large bolus of RBCs in a patient who likely has some renal dysfunction following trauma, hypotension, and surgery. In addition, all other answers seem incorrect based on the normal GGT and alk phos.

Maybe benign postoperative cholestasis? She has increased pigment load from all the transfusions with decreased urinary excretion and ability to conjugate all that bilirubin from hypotensive induced renal and liver dysfunction. Also with the bilirubin levels peaking around POD#10.

 

[seminoma]

Maybe benign postoperative cholestasis? She has increased pigment load from all the transfusions with decreased urinary excretion and ability to conjugate all that bilirubin from hypotensive induced renal and liver dysfunction. Also with the bilirubin levels peaking around POD#10.

I thought alk phos was elevated in postop cholestasis?

 

[dfib slim]

I thought alk phos was elevated in postop cholestasis?

Yup. It's elevated at 150 depending on what lab reference values you're using. UW lists upper limit as 115 for females.

 

[sebastopublican]

Nope, actually the answer to #2 is e) increased pulmonary vascular resistance (yes, the VSD reopened, but the cause of her cyanosis is now a R->L shunt - Eisenmenger syndrome). I just took NBME form 4 and this did not show up in my wrong answers.

 

[dfib slim]

I have a couple questions from the NBMEs. Shelf tomorrow.

I think you got them all except for #3. I'd go with strep pyogenes causing erysipelas. Also check out MVP syndrome as the cause for the palpitations.

 

[Winged Scapula]

PLEASE NOTE:

we have discussed this previously.

It is against the SDN Terms of Service to post actual questions from the examinations or review material, even that from the NBME.

You may paraphrase but word for word transcription of the questions is a copyright violation and is not allowed.

 

[Crayola227]

I have two on form 4, I'd like to discuss:


what are the correct answers and reasonings behind it? Thanks!

You can't post these on this site word for word. You need to paraphrase, and maybe not list that you're taking it right out of a test. Ask someone not on this board.

 

[Bluefunk]

Any ideas?
1. Person shot in leg and has absent pulses from popliteal down
2. XRay shows femoral fracture
3. Fracture reduced and immobilized

Next step?
1. Duplex ultrasound?
2. Measurement of ABI?
3. Surgery?

I was thinking ABI to see if reducing fracture had stopped the femoral artery occlusion. I'm assuming surgery is best

 

[Ismet]

Any ideas?
1. Person shot in leg and has absent pulses from popliteal down
2. XRay shows femoral fracture
3. Fracture reduced and immobilized

Next step?
1. Duplex ultrasound?
2. Measurement of ABI?
3. Surgery?

I was thinking ABI to see if reducing fracture had stopped the femoral artery occlusion. I'm assuming surgery is best

Ultrasound first. It's very quick, and if you're thinking surgery is necessary, you need to know location. Look up what an ABI is - it's used more for evaluation of PAD, not an acute process like this, and it can take quite a while to do and get results. AKA if you're thinking they may need vascular surgery imminently, waiting for the ABI isn't going to give you any valuable information and it would just waste time.

 

[mimelim]

Any ideas?
1. Person shot in leg and has absent pulses from popliteal down
2. XRay shows femoral fracture
3. Fracture reduced and immobilized

Next step?
1. Duplex ultrasound?
2. Measurement of ABI?
3. Surgery?

I was thinking ABI to see if reducing fracture had stopped the femoral artery occlusion. I'm assuming surgery is best

Ultrasound first. It's very quick, and if you're thinking surgery is necessary, you need to know location. Look up what an ABI is - it's used more for evaluation of PAD, not an acute process like this, and it can take quite a while to do and get results. AKA if you're thinking they may need vascular surgery imminently, waiting for the ABI isn't going to give you any valuable information and it would just waste time.

The most important test is to perform an ABI in the trauma bay. Anything abnormal (<0.9) mandates either a CTA or immediate operative exploration. I would get a CTA in patients that I suspect have underlying vascular disease that is clouding the ABI or in patients that I think the CTA will change my operative approach, ie. may be able to do something endo or different incision. Always reduce fracture before CTA or vascular intervention.

An ABI can be performed by anyone, it is not a time consuming test. At our trauma center (one of the busiest in the country), it is the MS3's job on trauma to get the ABIs on all extremity trauma patients. Duplex on the other hand is far more time consuming and does not give you any additional information in the absence of prior intervention.

Also, lack of pulse does not mean occlusion. It means less than ~90mmHg of pressure. 80% of my patients do not have palpable pedal pulses. Many have arterial occlusions, but most do not.

 

[Ismet]

The most important test is to perform an ABI in the trauma bay. Anything abnormal (<0.9) mandates either a CTA or immediate operative exploration. I would get a CTA in patients that I suspect have underlying vascular disease that is clouding the ABI or in patients that I think the CTA will change my operative approach, ie. may be able to do something endo or different incision. Always reduce fracture before CTA or vascular intervention.

An ABI can be performed by anyone, it is not a time consuming test. At our trauma center (one of the busiest in the country), it is the MS3's job on trauma to get the ABIs on all extremity trauma patients. Duplex on the other hand is far more time consuming and does not give you any additional information in the absence of prior intervention.

Also, lack of pulse does not mean occlusion. It means less than ~90mmHg of pressure. 80% of my patients do not have palpable pedal pulses. Many have arterial occlusions, but most do not.

I stand corrected! Thanks for the explanation. I just remember ordering an ABI for a couple inpatients in med school and it took forever for some reason.

 

[Bluefunk]

The most important test is to perform an ABI in the trauma bay. Anything abnormal (<0.9) mandates either a CTA or immediate operative exploration. I would get a CTA in patients that I suspect have underlying vascular disease that is clouding the ABI or in patients that I think the CTA will change my operative approach, ie. may be able to do something endo or different incision. Always reduce fracture before CTA or vascular intervention.

An ABI can be performed by anyone, it is not a time consuming test. At our trauma center (one of the busiest in the country), it is the MS3's job on trauma to get the ABIs on all extremity trauma patients. Duplex on the other hand is far more time consuming and does not give you any additional information in the absence of prior intervention.

Also, lack of pulse does not mean occlusion. It means less than ~90mmHg of pressure. 80% of my patients do not have palpable pedal pulses. Many have arterial occlusions, but most do not.

Thanks for the reply - what would you say the answer is (NBME says it is not ABI)?

 

[temporaryumm]

Can someone explain to me how the NBME score translate into percentile? I was looking up online and couldn't figure it out. I took my shelf last week and am worried that I didn't pass.

For example, my school requires 15% percentile to pass. The last NBME I took:
Number of questions wrong: 19 out of 50
Assessment score: 17/20
Approximate Subject Examination Score: 62

I initially thought that the "Approximate subject examination score" was the percentile and was really happy but I'm starting to think that I misinterpreted that.

Thanks!

 

[NWwildcat2013]

Just took my first NMBE and discovered that this shelf is just medicine with a few surgery questions mixed in. There were neuro questions, ONGYN questions, and all sorts of general medicine diagnoses. How can you really study for that? Thankfully my medicine is decent so it makes me wanna just take it easy and see what happens on the real thing. Such a weird shelf...


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[PhillyMed777]

where do you find pestana's audio?

 

[Southplains]

Thanks for the reply - what would you say the answer is (NBME says it is not ABI)?

This is what's frustrating about 3rd year shelves, because here we see a vascular surgeon saying he would do ABI first, but I just finished surgery and that question's answer was surgery.

 

[mimelim]

This is what's frustrating about 3rd year shelves, because here we see a vascular surgeon saying he would do ABI first, but I just finished surgery and that question's answer was surgery.

This isn't about 3rd year shelves, this is about medical education. You will find equally boneheaded questions on my in-service exam. I have no idea what the answer is that they are looking for. I can only say what we do in practice and that experts in the field think is best. *shrug*

 

[Southplains]

This isn't about 3rd year shelves, this is about medical education. You will find equally boneheaded questions on my in-service exam. I have no idea what the answer is that they are looking for. I can only say what we do in practice and that experts in the field think is best. *shrug*

Oh you're absolutely right, and that's the message I was really trying to send. In 3rd year, and by all accounts beyond that, you should know "what the exam wants" and then what is actually the approach you have seen in your experience.

 

[Jabbed]

Any ideas?
1. Person shot in leg and has absent pulses from popliteal down
2. XRay shows femoral fracture
3. Fracture reduced and immobilized

Next step?
1. Duplex ultrasound?
2. Measurement of ABI?
3. Surgery?

I was thinking ABI to see if reducing fracture had stopped the femoral artery occlusion. I'm assuming surgery is best

Pulselessness = surgery. In the absence of a "hard sign" of vascular injury, ABI would be indicated.

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[Jabbed]

i dont agree with you

Textbook answer for a textbook question.

 

[Cantankerous_hole]

Surgery Form 3 CSMS question:

A 22 year old man comes to the emergency department because of a swollen, painful, and slightly plethoric right lower extremity. He has had two episodes of superficial thrombophlebitis of the right lower extremity; the first episode occurred 30 months ago and the second episode occurred 18 months ago. Venous duplex scan confirms deep venous thrombosis involving the infrapopliteal veins.

select the most likely diagnosis.

A) Anticardiolipin antibodies
B) Antithrombin III deficiency
C) Fibrinogen abnormality
D) Hemophilia
E) Thrombathenia
F) Thrombocytopenia
G) Thrombocytosis
H) von Willebrand disease

G is wrong

Can anybody help with this question? Thanks.

 

[Quizlet04]

Surgery Form 3 CSMS question:

A 22 year old man comes to the emergency department because of a swollen, painful, and slightly plethoric right lower extremity. He has had two episodes of superficial thrombophlebitis of the right lower extremity; the first episode occurred 30 months ago and the second episode occurred 18 months ago. Venous duplex scan confirms deep venous thrombosis involving the infrapopliteal veins.

select the most likely diagnosis.

A) Anticardiolipin antibodies
B) Antithrombin III deficiency
C) Fibrinogen abnormality
D) Hemophilia
E) Thrombathenia
F) Thrombocytopenia
G) Thrombocytosis
H) von Willebrand disease

G is wrong

Can anybody help with this question? Thanks.

Probably B. One of the more common clotting disorders.

 

[Entadus]

Taking this bad boy tomorrow !!

I've read Pestana (75pg word doc) and will be repeating that right before the exam as last minute cramming (2x)

Also did UWorld Surgery(1x) +re-did incorrects

Used Recall early in the rotation for pimping (and to look like less of an idiot in the OR as an M3 with basically no experience) but not for shelf study.

Did NBME3/4 today; looks like I'm predicted around ~82(41+41). Hoping to get >80 on the real deal. I've already had IM (4 months ago) with similar results... hopefully I haven't forgotten everything since then...

Will post an update in a few days with the result.

EDIT: Things I might have added would be finishing Emma Holliday's Surgery review vid, and I think the NBME has some free online questions as well.

 

[doyouhaveaflag]

Taking this bad boy tomorrow !!

Will post an update in a few days with the result.

How'd it go today? I just finished a few hours ago. I'm pretty sure everyone at my school had the same form but not sure if different schools have the same form as us.

This is only my second shelf because our IM is 3 months long and we don't have an EM shelf. I felt OK coming out of the IM shelf and ended up doing very well. This one I came out feeling like I was repeatedly kicked in the gut. It was terrible. I wonder if this bodes poorly for me.

I scored between 87 and 96 on the clinical mastery series forms 1-4 but I felt like this was so much harder. I would be shocked if I got above an 80 at this point.

Is the surgery shelf known for being a beast compared to others?

 

[jpwsurf21]

97th percentile (86 raw). Came out of it feeling actually pretty confident except for maybe like 20 questions that I had flagged. Had done IM before surgery (86th percentile on IM) which was helpful in that I had already done all the medicine questions.

Useful Resources:

• *Pestana 2x. Did questions 1x + questions that I marked. Obviously a great and luckily quick book to read.
• *Devirgillio - highly recommend this book. ~700 pages but it goes quickly (vs NMS which seemed to drag forever). I didn't start using it until late in the clerkship but wish I had used it from the start since I didn't end up finishing it in time. Did the questions 1x + questions that I marked - these questions + answer explanations were great preparation for the Shelf
• *UWorld: All surgery questions x2 + Medicine for GI + Renal x1.5 (had already gone through these on medicine so it went pretty quickly)
• *NBME: Took a couple of them - scored >10 better on my actual shelf than the NBME. Definitely recommend this as it feels different from UWorld and obviously much more like the actual Shelf.
• *UTHSCSA Emma Ramahi Review video 1x a few days before the shelf. Always a good thing to do before the shelf
• NMS casebook 1x - not really worth it in my mind, especially if you're crunched for time
• OnlineMedEd - used for a few surgery topics. IMO too superficial and not really worth it but some people swear by it
• Lawrence textbook - did not touch so I have no idea

 

[Entadus]

How'd it go today? I just finished a few hours ago. I'm pretty sure everyone at my school had the same form but not sure if different schools have the same form as us.

This is only my second shelf because our IM is 3 months long and we don't have an EM shelf. I felt OK coming out of the IM shelf and ended up doing very well. This one I came out feeling like I was repeatedly kicked in the gut. It was terrible. I wonder if this bodes poorly for me.

I scored between 87 and 96 on the clinical mastery series forms 1-4 but I felt like this was so much harder. I would be shocked if I got above an 80 at this point.

Is the surgery shelf known for being a beast compared to others?

87 raw! super happy with it! (Percentile is somewhere in the 90's since avg was ~73 with STD=8)

-Know Spontaneous Bacterial Peritonitis and how to treat it
-Expect some ethics questions.. how do you handle consent with a person who is old? Low IQ? (how low?)
-How does intussusception present? Can you recognize it without the buzzwords?
-How do you treat Basal cell ca.? (Name of the surgery?)

 

[apr27]

from form 3

1)52 yo w/ 1 yr hx of difficulty swallowing, intermittent vomitting of digested food, caught at ight. Weight loss over past 6 mos. Has anxiety. Not a smoker or drinker. VSS.Normal PE.....CXR shows air-fluid level in post mediastinum at lvl of cardiac silhouette. Manometry shows normal LES pressures and absent LES relaxation with swallowing. Dx?

a) achalasia, b) diffuse esophageal spasm c) globus hystericus d)hiatal hernia e)systemic sclerosis

2)57 yo with 3 mo hx of 4-6 loose stools daily and 7.3 kg weight loss. Has 2-3 Bfs a week followinowgi 10 day course of tetracycline 2 mos ago. Antrectomy w/ Billroth II for perforated gastric ulcer 1 yr ago. no changes in diet. OA in hips. Skinfolds over abd. Abd is scaphoid w/ well healing surg. scar. Cause od diarrhea?

a) bacterial overgrowth, b)bile reflux c) COX-2 inhibition, D)dumping syndrome E) efferent loop obstruction

 

[jpwsurf21]

1) Achalasia - normally, at baseline the LES is tight and then relaxes with swallowing. The thing with achalasia wrt the LES is that it does not relax, hence the bird's beak.
2) pretty sure this was bacterial overgrowth

 

[Ryuzaki]

I was wondering if someone could help me with these following questions from NBME Form 3 from Surgery.

1. 57 y/o female w/3 month hx of cough, which has been increasing in freq the last month, has hemoptysis once. she is a smoker, was diagnosed with NSCLC (3 cm mass). Pre-op testing shows:
FEV1 for left Lung: 600 ml
Maximum voluntary ventilation: 50% of predicted
DCLO: 50% of predicted

ABG on Room Air shows:
PCO2: 44 mm Hg
Po2: 75 mm Hg

Which of the following parameters is likely the most useful in assessing this patients post-op risk for pneumonectomy?

A. Arterial pC02
B. Arterial Po2
C. DLCO
D. FEV1
E. MVV

2. 64 y/o male undergoes repair of AAA, mid operation retroaortic renal vein is lacerated, patient loses large amount of blood. He is given 4L of blood retained by the auto-transfusion device, 22 units of packed RBC are given. However patient is still bleeding from IV and Arterial catheter sites.

A. Anticardiolipin antibodies
B. Anti-Thrombin III Def.
C. Hemophilia
D. Thromboasthenia
E. Thrombocytopenia
F. Thrombocytosis
G. Fibrinogen Abnormality
H. von Williebrand Disease

3. 37 y/o woman comes to ER 12 hours after RLQ abdominal pain, nausea and decreased appetitie. RLQ Abdomen is tender to palpation, Pelvic exam is unremarkable. Leukocyte Count: 13,500 UA shows several WBC. Most appropriate next step?

A. Colon Contrast studies
B. Upper GI Series w/Small Bowel Follow Through
C. IV Pyleography
D. Culdocentesis
E. Appendectomy

4. 20 y/o man comes to the ED w/1 day after onset of fever and severe pain at the base of the spine between the gluteal folds. his temperature is 38.3 (101F). There is tender fullness with slight erythema between the gluteal folds over the coccyx. Which of the following is the most likely diagnosis?

A. Anal Fissure
B. Cellulits
C. Fistula in Ano
D. Perirectal abscess
E. Pilonidal abscess

I was really confused with this one, I picked Perirectal but it wasn't the answer.

5. A 3-week old female newborn is brought to the physician w/an 18-day hx of increasingly yellow skina nd eyes. She was born at term to a 24 y/o G2P2 w/uncomplicated pregnancy and delivery; birth weight: 7 lbs, exclusively breast-fed. Today she weighs 7 lbs, 6 oz. PE: scleral icterus and genearlized jaundice. Serum Total Bili: 15 mg/dl w/direct component of 13 mg/dL. What is the diagnosis?

A. ABO Incompataibility
B. Biliary Atresia
C. Breast Milk Jaundice
D. Gilbert Syndrome
E. Hereditary spherocytosis
F. Physiologic Jaundice

I went with C, here but it wasn't the answer, I was debating between that and Gilbert's.

 

[tennislover1989]

I was wondering if someone could help me with these following questions from NBME Form 3 from Surgery.

1. 57 y/o female w/3 month hx of cough, which has been increasing in freq the last month, has hemoptysis once. she is a smoker, was diagnosed with NSCLC (3 cm mass). Pre-op testing shows:
FEV1 for left Lung: 600 ml
Maximum voluntary ventilation: 50% of predicted
DCLO: 50% of predicted

ABG on Room Air shows:
PCO2: 44 mm Hg
Po2: 75 mm Hg

Which of the following parameters is likely the most useful in assessing this patients post-op risk for pneumonectomy?

A. Arterial pC02
B. Arterial Po2
C. DLCO
D. FEV1
E. MVV

2. 64 y/o male undergoes repair of AAA, mid operation retroaortic renal vein is lacerated, patient loses large amount of blood. He is given 4L of blood retained by the auto-transfusion device, 22 units of packed RBC are given. However patient is still bleeding from IV and Arterial catheter sites.

A. Anticardiolipin antibodies
B. Anti-Thrombin III Def.
C. Hemophilia
D. Thromboasthenia
E. Thrombocytopenia
F. Thrombocytosis
G. Fibrinogen Abnormality
H. von Williebrand Disease

3. 37 y/o woman comes to ER 12 hours after RLQ abdominal pain, nausea and decreased appetitie. RLQ Abdomen is tender to palpation, Pelvic exam is unremarkable. Leukocyte Count: 13,500 UA shows several WBC. Most appropriate next step?

A. Colon Contrast studies
B. Upper GI Series w/Small Bowel Follow Through
C. IV Pyleography
D. Culdocentesis
E. Appendectomy

4. 20 y/o man comes to the ED w/1 day after onset of fever and severe pain at the base of the spine between the gluteal folds. his temperature is 38.3 (101F). There is tender fullness with slight erythema between the gluteal folds over the coccyx. Which of the following is the most likely diagnosis?

A. Anal Fissure
B. Cellulits
C. Fistula in Ano
D. Perirectal abscess
E. Pilonidal abscess

I was really confused with this one, I picked Perirectal but it wasn't the answer.

5. A 3-week old female newborn is brought to the physician w/an 18-day hx of increasingly yellow skina nd eyes. She was born at term to a 24 y/o G2P2 w/uncomplicated pregnancy and delivery; birth weight: 7 lbs, exclusively breast-fed. Today she weighs 7 lbs, 6 oz. PE: scleral icterus and genearlized jaundice. Serum Total Bili: 15 mg/dl w/direct component of 13 mg/dL. What is the diagnosis?

A. ABO Incompataibility
B. Biliary Atresia
C. Breast Milk Jaundice
D. Gilbert Syndrome
E. Hereditary spherocytosis
F. Physiologic Jaundice

I went with C, here but it wasn't the answer, I was debating between that and Gilbert's.

I can help with a few of these.
1. A --> FEV1/FVC ratio is the best prognostic indicator.
2. E --> pt. lost a significant amount of blood and was given PRBCs but no platelets so hemostasis is impaired.
4. E --> Pilodonal abscess; for me the clue was the lesion being near the coccyx. Usually in men due to more hair in that area.

 

[Alby]

I would go with colon contrast study for #3. If the appendix does not fill, then appendectomy.

#5 Biliary atresia



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[W19]

I am getting crushed by Uworld... I read MTB and it's not helping. I am going to see if I can squeeze in Pestana... Anything else I should do?

 

[jpwsurf21]

I am getting crushed by Uworld... I read MTB and it's not helping. I am going to see if I can squeeze in Pestana... Anything else I should do?

Keep going through Uworld (surgery, GI, Renal) multiple times and use pestana. I haven't used MTB but I think I can say with certainty that Pestana is much better for the shelf and should be a very high priority.

 

[ortnakas]

Keep going through Uworld (surgery, GI, Renal) multiple times and use pestana. I haven't used MTB but I think I can say with certainty that Pestana is much better for the shelf and should be a very high priority.

Second this. I admittedly scraped by on the surgery shelf, but Pestana was the single most useful resource I used. You can get through the Pestana book quickly but if you can find the time, I've heard the audio/video is excellent, too. I used OnlineMedEd and it definitely helped me pass, but if you're going for a great score I think there's probably better options.

 

[Anicetus]

Keep going through Uworld (surgery, GI, Renal) multiple times and use pestana. I haven't used MTB but I think I can say with certainty that Pestana is much better for the shelf and should be a very high priority.

Went through pestana 4x with the vignettes for Kaplan in addition to that.
Uworld surgery x2 with medicine GIx2, neurox1, renalx1, pulmx1,
Skimmed devirgilio X1 because I didn't have enough time in total outside of floor duties/assignments on surgery.

Scaled score: 72.

Pestana is good enough for passing. You'll need something more in depth like NMS (big book) if you want to tackle the detailed stuff. Uworld IM ideally is what will help since shelf is mostly IM material.

My clerkship slammed me with bad hours and tons of ridiculous assignments to complete leaving me little time to visit other more detailed sources. The only way I could've done more was to ditch more surgeries and call in sick more often/make up dean meetings as excuses not to go into surgeries and tackle an in depth book like NMS or devirgilio a couple of times. That or modafinil to not sleep to allow for more time.

 

[W19]

Scaled score: mid 80s...

Thought I failed... That shelf exam was the worst!

 

[Redpancreas]

I would go with colon contrast study for #3. If the appendix does not fill, then appendectomy.

#5 Biliary atresia

Agree with #5. For #3, I would say appendectomy because of the WBCs on UA (perforation of appendix affected bladder, ureter, etc.) and RLQ pain and the age matches. I could see how one could think nephrolithiasis though. Very tricky!


Also, is it just me or is OME an exact copy of the Pestana book? Like literally all the same buzzwords and explanations in a different order. Pestana's slightly more detailed.

 

[doyouhaveaflag]

I was wondering if someone could help me with these following questions from NBME Form 3 from Surgery.

1. 57 y/o female w/3 month hx of cough, which has been increasing in freq the last month, has hemoptysis once. she is a smoker, was diagnosed with NSCLC (3 cm mass). Pre-op testing shows:
FEV1 for left Lung: 600 ml
Maximum voluntary ventilation: 50% of predicted
DCLO: 50% of predicted

ABG on Room Air shows:
PCO2: 44 mm Hg
Po2: 75 mm Hg

Which of the following parameters is likely the most useful in assessing this patients post-op risk for pneumonectomy?

A. Arterial pC02
B. Arterial Po2
C. DLCO
D. FEV1
E. MVV

2. 64 y/o male undergoes repair of AAA, mid operation retroaortic renal vein is lacerated, patient loses large amount of blood. He is given 4L of blood retained by the auto-transfusion device, 22 units of packed RBC are given. However patient is still bleeding from IV and Arterial catheter sites.

A. Anticardiolipin antibodies
B. Anti-Thrombin III Def.
C. Hemophilia
D. Thromboasthenia
E. Thrombocytopenia
F. Thrombocytosis
G. Fibrinogen Abnormality
H. von Williebrand Disease

3. 37 y/o woman comes to ER 12 hours after RLQ abdominal pain, nausea and decreased appetitie. RLQ Abdomen is tender to palpation, Pelvic exam is unremarkable. Leukocyte Count: 13,500 UA shows several WBC. Most appropriate next step?

A. Colon Contrast studies
B. Upper GI Series w/Small Bowel Follow Through
C. IV Pyleography
D. Culdocentesis
E. Appendectomy

4. 20 y/o man comes to the ED w/1 day after onset of fever and severe pain at the base of the spine between the gluteal folds. his temperature is 38.3 (101F). There is tender fullness with slight erythema between the gluteal folds over the coccyx. Which of the following is the most likely diagnosis?

A. Anal Fissure
B. Cellulits
C. Fistula in Ano
D. Perirectal abscess
E. Pilonidal abscess

I was really confused with this one, I picked Perirectal but it wasn't the answer.

5. A 3-week old female newborn is brought to the physician w/an 18-day hx of increasingly yellow skina nd eyes. She was born at term to a 24 y/o G2P2 w/uncomplicated pregnancy and delivery; birth weight: 7 lbs, exclusively breast-fed. Today she weighs 7 lbs, 6 oz. PE: scleral icterus and genearlized jaundice. Serum Total Bili: 15 mg/dl w/direct component of 13 mg/dL. What is the diagnosis?

A. ABO Incompataibility
B. Biliary Atresia
C. Breast Milk Jaundice
D. Gilbert Syndrome
E. Hereditary spherocytosis
F. Physiologic Jaundice

I went with C, here but it wasn't the answer, I was debating between that and Gilbert's.

These are the answers I put (confirmed correct b/c not in my incorrects):
1. D (FEV1)
2. B (ATIII def)
3. E (go straight to appy)
4. E (pilonidal abscess)
5. B (biliary atresia - note the direct component)

Edit: Whoops didn't realize you had posted so long ago. Probably not useful to you now. Maybe it will be to someone else though.

 

[Qester]

What is the go to resources for this shelf?

I was looking at doing

Pestana
uWorld
NMS Big Book as time permits

am i missing any gold resource?

 

[Merely]

Anyone know where to get pestana audio files?

 

[t5Nitro]

What is the go to resources for this shelf?

I was looking at doing

Pestana
uWorld
NMS Big Book as time permits

am i missing any gold resource?

I was looking at Pestana, NMS surgery casebook, and surgical recall (+Lawrence required by my school).

Is anyone kind enough to comment on if this is a good list or too heavy for the amount of time you had on surgery? What is the best way to utilize these books during the rotation?

edit: can I ask how people are using OME during these rotations? Is it enough to watch the videos and go through the notes or do you recommend using the other resources available through this resource?

 

[bunya12]

NBME shelf in a few weeks, study plan is memorize all of OME surgery, Pestana 2x, and all UW surgery and IM gi questions. Is this enough to do well (90+ percentile) or should I be doing something else in addition and/or in place of these? Thanks!


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