Surgery: NBME 1 and 2 thread

[drchandrasika]

Feel free to post any questions, answers, and explanations for both Surgery NBMES(1 & 2). Also if anyone can copy paste the questions and explanations randomly spread out on the student doc website onto this thread, that would just be amazing(In case you randomly come across some).

---

Members don't see this ad.

 

[abelabbot]

bump

 

[Bancrofti]

An 18-y/o man is brought to the ED b/c of pain in the right hip and flank after a MVC. He is alert and stable. Examination shows abrasions, ecchymoses, and tenderness over the Rt iliac crest, and abrasions on the right flank. UA shows gross blood. Xray of the cervical spine is normal. Next step in diagnosis?

CT abdomen, MRI pelvis, Radionuclide renal scan, selective renal angiography, cystoscopy

 

[abelabbot]

37 primigravida woman who is 6 months pregnant has s(x) of carpal tunnel syndrome. Ibuprofen usage and breaks from using computer relieved s(x) before, but have now become difficult to control during pregnancy. Uterus size shows 26 week gestation. Best way to confirm d(x)?

I put "x-rays of the hands and wrists" but I got it wrong. The answer I believe is "nerve conduction studies". Why is this the case? I looked this up in pestana on page 36 which states "The diagnosis is clinical, but the American Academy of Orthopedic Surgery recommends that wrist x-rays (including carpal tunnel view) be done to rule out other things"(Pestana, 36). "If surgery is needed, electromyography should precede it (electro-diagnostic studies of nerve conduction)." (Pestana, 36)

However the stem doesn't mention anything about the woman needing surgery right away. If someone can please explain this, that would be great! @Phloston

 

[Phloston]

An 18-y/o man is brought to the ED b/c of pain in the right hip and flank after a MVC. He is alert and stable. Examination shows abrasions, ecchymoses, and tenderness over the Rt iliac crest, and abrasions on the right flank. UA shows gross blood. Xray of the cervical spine is normal. Next step in diagnosis?

CT abdomen, MRI pelvis, Radionuclide renal scan, selective renal angiography, cystoscopy

My guess would be CT abdomen. It doesn't seem like they're giving any info that would support a bladder/urethral injury, and MRI, RRS and angiography all seem too invasive. CT abdomen seems fairly standard.

I made a PPT of my incorrect clinical mastery series and NBME questions through extended feedback, and this above Q isn't one of them. So I'm assuming it's CT abdomen that I answered originally.

 

[Phloston]

37 primigravida woman who is 6 months pregnant has s(x) of carpal tunnel syndrome. Ibuprofen usage and breaks from using computer relieved s(x) before, but have now become difficult to control during pregnancy. Uterus size shows 26 week gestation. Best way to confirm d(x)?

I put "x-rays of the hands and wrists" but I got it wrong. The answer I believe is "nerve conduction studies". Why is this the case? I looked this up in pestana on page 36 which states "The diagnosis is clinical, but the American Academy of Orthopedic Surgery recommends that wrist x-rays (including carpal tunnel view) be done to rule out other things"(Pestana, 36). "If surgery is needed, electromyography should precede it (electro-diagnostic studies of nerve conduction)." (Pestana, 36)

However the stem doesn't mention anything about the woman needing surgery right away. If someone can please explain this, that would be great! @Phloston

X-rays often don't show anything for carpal tunnel syndrome. But nerve conduction studies will. And if you get a question as to the mechanism for CTS in pregnancy, the answer is increased fluid in the carpal tunnel (not extracellular matrix deposition or anything like that).

 

[Phloston]

#4: The pt has undiagnosed T2DM or is pre-diabetic --> decreased efficacy of diapedesis due to non-enzymatically glycosylated vessels + loss of immunoglobulins in urine --> decreased immune response. Candida in a fat person always = diabetes. That's actually an NBME question too. They try to make tinea cruris look like contact dermatitis but it's just the fact that she's diabetic. And just for the record, Candida in the oropharynx = asthma w/ steroids, immunosuppresion (e.g., HIV) or diabetes.

#5: Age 13 actually fits SCFE perfectly. LCP disease you think 8 year-old = avascular necrosis = shrunken/shriveled femoral head.

#6: Sound of the murmur suggests occlusion of mitral valve during diastole, so it's either MS or myxoma. Myxoma classically causes a ball in valve obstruction. The pt lying on his right side moves the myxoma out of the way. AND this guy has weight loss (cancer). Myxomas classically = left atrium in adults. If it's a kid or TSC though it's rhabdomyoma/rhabdomyosarcoma.

 

[abelabbot]

#4: The pt has undiagnosed T2DM or is pre-diabetic --> decreased efficacy of diapedesis due to non-enzymatically glycosylated vessels + loss of immunoglobulins in urine --> decreased immune response. Candida in a fat person always = diabetes. That's actually an NBME question too. They try to make tinea cruris look like contact dermatitis but it's just the fact that she's diabetic. And just for the record, Candida in the oropharynx = asthma w/ steroids, immunosuppresion (e.g., HIV) or diabetes.

#5: Age 13 actually fits SCFE perfectly. LCP disease you think 8 year-old = avascular necrosis = shrunken/shriveled femoral head.

#6: Sound of the murmur suggests occlusion of mitral valve during diastole, so it's either MS or myxoma. Myxoma classically causes a ball in valve obstruction. The pt lying on his right side moves the myxoma out of the way. AND this guy has weight loss (cancer). Myxomas classically = left atrium in adults. If it's a kid or TSC though it's rhabdomyoma/rhabdomyosarcoma.

Appreciate it Phloston. Thank you

 

[abelabbot]

1) 28 YOW recently gained 80 lbs, which she atributes to stress. BMI is 40. BP 130/85. He obesity puts her at greatest risk for developing? Answer was cholecystitis.

Just to make sure, I shouldn't get thrown off by the fat, female, FORTY mnemonic right? meaning a person can be relatively young, but still have a risk factor for gallstones such as obesity, eventually leading to cholecystitis right?

2) 57 year old woman w/ 1 day of fever, chills, weakness. Had spleen taking out for ITP 10 years ago. Got blood and appropriate immunizations at that time. Temperature is 102.8, P 100, RR 20, BP 80/50. Crackles at right lung base. Chest xray shows signs of pneumonia. Most appropriate next step in management? Answer is vancomycin and ceftriaxone.

Please explain why this is the answer and not quinine and clindamycin for example.

 

[Phloston]

1) 28 YOW recently gained 80 lbs, which she atributes to stress. BMI is 40. BP 130/85. He obesity puts her at greatest risk for developing? Answer was cholecystitis.

Just to make sure, I shouldn't get thrown off by the fat, female, FORTY mnemonic right? meaning a person can be relatively young, but still have a risk factor for gallstones such as obesity, eventually leading to cholecystitis right?

2) 57 year old woman w/ 1 day of fever, chills, weakness. Had spleen taking out for ITP 10 years ago. Got blood and appropriate immunizations at that time. Temperature is 102.8, P 100, RR 20, BP 80/50. Crackles at right lung base. Chest xray shows signs of pneumonia. Most appropriate next step in management? Answer is vancomycin and ceftriaxone.

Please explain why this is the answer and not quinine and clindamycin for example.

#1) No, don't get pulled into the 4Fs plot. That's more of a QBank thing quite honestly. The NBME will throw at you whatever presentation it wishes. If a woman is obese, she likely has a lot of estrogen causing gallbladder stasis + higher cholesterol levels.

#2) Well just think about what vancomycin + ceftriaxone do. Vancomycin hardcore hits gram(+)s. Ceftriaxone is pretty versatile, hardcore AND has gram(-) coverage. If someone's without a spleen, he or she is notably at risk of infection by S. pneumoniae, Salmonella, Klebsiella, E. coli, H. influenzae and Babesia. Quinine and clindamycin is an older Tx for Babesia, but vancomycin + ceftriaxone will hit a nice diversity of gram(+)s and (-)s. That's also the empirical Tx for meningitis for the same reason (but you'd add steroids for S. pneumoniae and ampicillin for Listeria).

 

[Bancrofti]

My guess would be CT abdomen. It doesn't seem like they're giving any info that would support a bladder/urethral injury, and MRI, RRS and angiography all seem too invasive. CT abdomen seems fairly standard.

I made a PPT of my incorrect clinical mastery series and NBME questions through extended feedback, and this above Q isn't one of them. So I'm assuming it's CT abdomen that I answered originally.

You're right. I convinced myself that it shouldn't be CT Abdomen, because it should say CT abdomen/pelvis. In reality though none of the other answers are better and I did read afterwards that CT scan is the standard test for suspected kidney injury. Thanks Phloston!

 

[abelabbot]

thank you

 

[Smurfette]

Feel free to post any questions, answers, and explanations for both Surgery NBMES(1 & 2). Also if anyone can copy paste the questions and explanations randomly spread out on the student doc website onto this thread, that would just be amazing(In case you randomly come across some).

A general reminder to users: copying and pasting copyrighted questions verbatim is a violation of the TOS and publishers have been known to seek action against those who violate copyright. If you wish to discuss a question, make sure to re-word the question or summarize it rather than copying it.

 

[Winged Scapula]

Feel free to post any questions, answers, and explanations for both Surgery NBMES(1 & 2). Also if anyone can copy paste the questions and explanations randomly spread out on the student doc website onto this thread, that would just be amazing(In case you randomly come across some).

This is a violation of the SDN Terms of Service and in violation of the NBME copyright.