Jul 7, 2014
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1. previously healthy 47yo man comes to physician because of 2wk history of fatigue and progressive abdominal swelling. P/E abdominal distension and shifting dullness. Bowel sounds normal. No tenderness, mass, or organomegaly. Diagnostic paracentesis yields 50ml milky chylous fluid. Cause of findings?

choose between lymphoma or portal vein thrombosis? Both can cause chylous ascites. The latter one is a rare cause of chylous ascites but given this pt history (previously healthy, no mass, no other symptoms of lymphoma), is idiopathic portal vein thrombosis more likely?

2. 18YO man to ED because of pain in right hip and flank after MVA. He’s alert and stable. P/E abrasions, ecchymoses, tenderness over right iliac crest, and abrasions on right flank. U/A show gross blood. X-ray of cervical spine normal. Next step?

a) CT abdomen w/ contrast

b) MRI pelvis

c) radionuclide renal scan

d) selective renal angiography

3) cystoscopy

3. A 52-year-old woman with well-controlled type 2 diabetes mellitus is brought to the emergency department 24 hours after the onset of abdominal pain. She has vomited three times in the emergency department. She appears toxic. She is 157 cm (5 ft 2 in) tall and weighs 95 kg (210 lb); BMI is 38 kg/m2. Her temperature is 39.5°C (103.1°F), pulse is 120/min, respirations are 28/min, and blood pressure is 160/90 mm Hg. Examination shows scleral icterus. Breath sounds are decreased over the lower lung fields bilaterally. The abdomen is mildly tender; bowel sounds are normal. Rectal examination shows no abnormalities. Laboratory studies show:

Hemoglobin 12.6 g/dL

Leukocyte count 16,000/mm3

Segmented neutrophils 70%

Bands 10%

Lymphocytes 20%

Serum

Na+ 130 mEq/L

Cl− 90 mEq/L

K+ 5.0 mEq/L

HCO3− 14 mEq/L

Glucose 600 mg/dL

Bilirubin

Total 5.2 mg/dL

Direct 2.0 mg/dL

Alkaline phosphatase 350 U/L

AST 300 U/L

Amylase 100 U/L

Which of the following is the most likely diagnosis?

A) Acute pancreatitis

B) Amebic liver abscess

C) Biliary cirrhosis

D) Cholangitis, ascending

E) Chronic cholecystitis

F) Hepatitis

G) Pancreatic cancer


4. following diagnosis of ectopic pregnancy in a married 25yo woman, an abdominal operation is performed. However, examination of abdomen shows normal uterine pregnancy but an acutely inflamed appendix. An appendectomy is performed despite the fact that operative permit authorized only a surgical procedure for ectopic pregnancy.

a)appropriate in view of medical necessity to remove inflamed appendix

b)appropriate only if consent was obtained from spouse

c)inappropriate, because it constituted an unauthorized extension of field of surgery

d)inappropriate, because the pt had not previously been informed of risks associated with an appendectomy

choose C?

5. 80yo woman atherosclerosis and chornic atrial fibrillation has had severe midabdominal pain for 4 hours. P/E mild abdominal tenderness and absent bowel sounds; no masses or signs of peritoneal irritation. Stool occult blood positive. Wbc 28,340 w/ 65% segmented neutrophils, 20% bands, 15% lymphocytes. PH 7.18, Pco2 35, Po2 62. X-ray of abdomen show nonspecific gas pattern . next step?

a)colonoscopy

b)exploratory celiotomy

c)gastroscopy

d)laparoscopy (wrong)

e) peritoneal lavage
 

Distant

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Jul 8, 2014
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1) I'd go with Lymphoma > Damage the Lymphoid Circulation > Chylous Ascitis.
Portal vein thrombosis doesn't cause "Chylous" ascitis.

2) A, Looks like a Right side Renal Laceration. MRI is generally done in Electave cases and would need an abdominal MRI (not a Pelvic MRI), Radionuclide scan is done if CT is negative desptite high suspicion of a Renal lecration. Renal Angio could be done for Renal Artery Stenosis OR in this case for treatment of Severe intractable bleeding of a renal laceration in an unstable pt. Cystoscopy should be done in elective cases when you suspect a bladder tumor.

3) D, Cholangitis, ascending. She has the Gall stones Risk Factors "Forty, Female, Fatty" which can be complicated by Cholangitis. And by Exclusion. The Acute Picture Rules out Amebic Liver Abscess and Chronic Cholecystitis and Biliary Cirrhosis. The Normal Amylase rules out Acute Pancreatitis and the Fever and Leukocytosis rules out Pancreatic Cancer. and the Hepatitis presents Sub-acutely which is not the case here.

4) A, I'd Go with A.

5) B, The pt has Bowel Necrosis, Supported by bloody stool and leukocytosis and Metabolic Acidosis, No tenderness upon abdominal palpation. along with the Atrial Fibrillation. Must do a Laparotomy [Celiotomy] to rescect the damaged bowel immediately.

@CaliAtenza
 
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lordman

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@vincentannie Do you have the form offline? I have just completed this crazy form but many questions I did not feel comfortable with. Really need to have the form. Those NBME folks are really greedy! At least we should have all questions for our feedback- not just the wrong ones!
 
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Any help with this 1 question from the surgery forms, have tried my best to summarize it without leaving any key info out.

Thanks

77 yo female from nursing home taken to ED with complains of fever and vomiting for 2 days. Pt is alert, unable to provide history, asks repeatedly for water. Her temp is 38.6C (101.5F), and bp is 100/60 mm Hg. PE shows a distended, nontender abdomen with sparse high-pitched bowel sounds. Her supine x-ray of the abd shows multiple dilated loops of small bowel and gas within the small bowel lumen and within the liver. Which of the following is the most likely cause of these findings?
A) Bacterial cholangitis caused by Klebsiella pneumoniae
B) Cholecystoduodenal fistula with an impacted gallstone
C) Emphysematous cholecystitis with an intrahepatic perforation
D) Perforated duodenal ulcer with a subhepatic abscess
E) Pylephlebitis caused by sigmoid diverticulitis
 

lordman

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Dec 23, 2010
195
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Form 1:

1) What is the correct answer for the case of FAP? proctocolectomy with ilioanal resorvoir.
2) The case of (septicemia?) following diverticulitis surgery and seems inflamed afterward. What is the organism? I answered E.Coli but was wrong! Is it bacteroides?
3) The 52 yo woman with stippled calcifications on mammogram. No palpable masses. Next step? FNA was wrong! What is correct answer?
4) A kid with linear temporal skull fracture. What is the finding on CT? There were all types of cranial hemorrhages and meningitis. Did not really understand the question!
5) Nephrolithiasis case. Asking what is the finding on UA? WBC was a choice but it was normal. Is "RBC cells " the correct answer?
6) CRF case undergoing elective cholecystectomy asking what do you need to correct before the surgery! She has high K and PO4, PH 7.3. Really did not understand it!
7) Case of aortic rupture. Asking what to do? I picked exploratory thoracotomy but was wrong!! C'mon!!
8) Fluid replacement for burns case. Is the clue Parkland formula? Is it 15 L Ringer's lactate? (9.5L was wrong)

9) AV fistula case. I answered it PE. But seems the correct high output congestive heart failure. But c'mon! does this really happen is just 24 hours!! Seriously!!

10) The guy with bullet in his calf. I answered it wound irrigation and was wrong!
 
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Distant

Never Give Up!
Jul 8, 2014
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Any help with this 1 question from the surgery forms, have tried my best to summarize it without leaving any key info out.

Thanks

77 yo female from nursing home taken to ED with complains of fever and vomiting for 2 days. Pt is alert, unable to provide history, asks repeatedly for water. Her temp is 38.6C (101.5F), and bp is 100/60 mm Hg. PE shows a distended, nontender abdomen with sparse high-pitched bowel sounds. Her supine x-ray of the abd shows multiple dilated loops of small bowel and gas within the small bowel lumen and within the liver. Which of the following is the most likely cause of these findings?
A) Bacterial cholangitis caused by Klebsiella pneumoniae
B) Cholecystoduodenal fistula with an impacted gallstone
C) Emphysematous cholecystitis with an intrahepatic perforation
D) Perforated duodenal ulcer with a subhepatic abscess
E) Pylephlebitis caused by sigmoid diverticulitis

B, This is most likely a "Gall Stone Ileus" which is caused by a Chronic Gall stones > irritation of the Gall bladder wall > Creating a fistula between the gall bladder and the duodenum > Stone passes and gets impacted in the Ileocecal Valve > Bowel obstruction as seen in this patient "High pitch bowel sound = borborigmi = hyper active bowel sounds secondary to obstruction" also supported by the multiple DILATED bowel loops and gas within the liver as gas passes through the fistula.
 
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lordman

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Dec 23, 2010
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That question of a complication following cardiac cath. I was confused between HIT VS cholesterol embolization syn. I answered it correctly but forgot which one I picked! The case made me so confused!
 

lordman

5+ Year Member
Dec 23, 2010
195
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  1. Medical Student
Form 1:

1) What is the correct answer for the case of FAP? proctocolectomy with ilioanal resorvoir.

2) The case of (septicemia?) following diverticulitis surgery and seems inflamed afterward. What is the organism? I answered E.Coli but was wrong! Is it bacteroides?

3) The 52 yo woman with stippled calcifications on mammogram. No palpable masses. Next step? FNA was wrong! What is correct answer?

4) A kid with linear temporal skull fracture. What is the finding on CT? There were all types of cranial hemorrhages and meningitis. Did not really understand the question!

5) Nephrolithiasis case. Asking what is the finding on UA? WBC was a choice but it was normal. Is "RBC cells " the correct answer?

6) CRF case undergoing elective cholecystectomy asking what do you need to correct before the surgery! She has high K and PO4, PH 7.3. Really did not understand it!

7) Case of aortic rupture. Asking what to do? I picked exploratory thoracotomy but was wrong!! C'mon!!

8) Fluid replacement for burns case. Is the clue Parkland formula? Is it 15 L Ringer's lactate? (9.5L was wrong)

9) AV fistula case. I answered it PE. But seems the correct high output congestive heart failure. But c'mon! does this really happen is just 24 hours!! Seriously!!

10) The guy with bullet in his calf. I answered it wound irrigation and was wrong!

11) That question of a complication following cardiac cath. I was confused between HIT VS cholesterol embolization syn. I answered it correctly but forgot which one I picked! The case made me so confused!

@noxe @Distant
 
Feb 1, 2012
23
6
Status
  1. Medical Student
Form 1:

1) What is the correct answer for the case of FAP? proctocolectomy with ilioanal resorvoir.
2) The case of (septicemia?) following diverticulitis surgery and seems inflamed afterward. What is the organism? I answered E.Coli but was wrong! Is it bacteroides?
3) The 52 yo woman with stippled calcifications on mammogram. No palpable masses. Next step? FNA was wrong! What is correct answer?
4) A kid with linear temporal skull fracture. What is the finding on CT? There were all types of cranial hemorrhages and meningitis. Did not really understand the question!
5) Nephrolithiasis case. Asking what is the finding on UA? WBC was a choice but it was normal. Is "RBC cells " the correct answer?
6) CRF case undergoing elective cholecystectomy asking what do you need to correct before the surgery! She has high K and PO4, PH 7.3. Really did not understand it!
7) Case of aortic rupture. Asking what to do? I picked exploratory thoracotomy but was wrong!! C'mon!!
8) Fluid replacement for burns case. Is the clue Parkland formula? Is it 15 L Ringer's lactate? (9.5L was wrong)

9) AV fistula case. I answered it PE. But seems the correct high output congestive heart failure. But c'mon! does this really happen is just 24 hours!! Seriously!!

10) The guy with bullet in his calf. I answered it wound irrigation and was wrong!

1) Ans is Proctocolectomy (Done in FAP and UC )

2) Not 100% sure, but I think its B.Fragilis :
B. fragilis is involved in 90% of anaerobic peritoneal infections.
It acts primarily at the surface of the mucosa. It predominates in bacteremia associated with intraabdominal infections, peritonitis and abscesses following rupture of viscus, and subcutaneous abscesses or burns near the anus

3) Needle localized open biopsy
- Needle localization under US guidance may be performed on nonpalpable lesions with calcifications to localize a mass for open biopsy
- FNA can be performed on palpable lesions or through US localization; it can be performed quickly with a high sensitivity and specificity by an experienced clinician, but cannot differentiate between in situ and invasive carcinoma
- Core biopsy provides a better definitive histologic diagnosis and can determine if a lesion is invasive

4) Ans: Epidural hematoma , the following is from Medscape: Linear fracture results from low-energy blunt trauma over a wide surface area of the skull. It runs through the entire thickness of the bone and, by itself, is of little significance except when it runs through a vascular channel, venous sinus groove, or a suture. In these situations, it may cause epidural hematoma, venous sinus thrombosis and occlusion, and suturaldiastasis, respectively.

5) RBC 30/hpf is the right answer due to microscopic hematuria I believe, wish I had a better explanation

6) Ans is E : Initiate dialysis , Pt has high output renal failure
Indications for DIALYSIS are severe hyperkalemia, severe metabolic acidosis, fluid overload in CRF and CHF, uremic syndrome, CKD with Cr >12 mg/dL and BUN>100 mg/dL

7) Ans is A: Aortic Arteriography (possible aortic dissection, CT wasn't an option or was negative?, next best step is aortic arteriography)

8) Yes answer is 15 L of Lactated Ringer solution : Use parkland forumla (4 x 50% x 75 kg) = 15L

9) High output cardiac failure ; she has JVD, S3, S4 present , also no edema of sacrum or exretemities kinda pushes you away from PE/DVT

10) Answer is surgical decompression, the scenario is trying to lead you to think compartment syndrome
 
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Feb 1, 2012
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That question of a complication following cardiac cath. I was confused between HIT VS cholesterol embolization syn. I answered it correctly but forgot which one I picked! The case made me so confused!

That q's answer was HIT, classic HIT scenario, isolated low platelets, recevied heparin 3 days ago.
 
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lordman

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Dec 23, 2010
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@noxe Thanks man. I re-read #2 and found the word "crepitant" so I guess it's clostridium perifringis....
 

lordman

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Dec 23, 2010
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The alcoholic pancreatitis question. Ca is 7.7. Which is the most appropriate intravenous administration?

- calcium gluconate
- Ringer's lactate


I remember I got it right, but does not recall the answer! Any help? I guess Ringer's (fluid) is superior here. Any confirmation from people solved the question?
 
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Distant

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Jul 8, 2014
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Why would you wanna prioritize hydration in a HYPOcalcemic Pt?
Of only these were the answers, I'd go with Calcium Gluconate. Hydration is for HYPERCalcemia..
But the Answer might be Neither...
 
Jul 7, 2014
13
1
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  1. Medical Student
@vincentannie Do you have the form offline? I have just completed this crazy form but many questions I did not feel comfortable with. Really need to have the form. Those NBME folks are really greedy! At least we should have all questions for our feedback- not just the wrong ones!
sorry.. i only have the questions i got wrong..
 
Jul 25, 2013
63
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1 yo. boy with persistent cough, loose stools, and facial rash for 2 mo. 4lb. weight loss. Normal appetite and activity, no hx of fever. 98.6F, 100bpm, 18/min, and 80/50 mmHg. Malar flush and abdominal dissension on exam. CT shows small tumor localized to pancreas. Tumor is surgically removed with no problems. Diagnosis?

A) Insulinoma.
B) Glucagonoma.
C) Pancreatic pseudocyst.
E) VIP-secreting tumor.

I'd appreciate the help! :)
 
Jul 25, 2013
63
1
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  1. DO/PhD Student
42 yo. pt. admitted with a piece of meat lodged in the lower esophagus. With difficulty, the meat was removed with esophagoscopy. In the evening, he develops a 101F fever. Next diagnostic study?

A) CT of chest.
B) Lateral x-rays of neck.
C) MRI of chest.
D) Repeated esophagoscopy.
E) Water- soluble contrast upper GI study.

Could really use the help....
 
Jul 9, 2014
17
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1 yo. boy with persistent cough, loose stools, and facial rash for 2 mo. 4lb. weight loss. Normal appetite and activity, no hx of fever. 98.6F, 100bpm, 18/min, and 80/50 mmHg. Malar flush and abdominal dissension on exam. CT shows small tumor localized to pancreas. Tumor is surgically removed with no problems. Diagnosis?

A) Insulinoma.
B) Glucagonoma.
C) Pancreatic pseudocyst.
E) VIP-secreting tumor.

I'd appreciate the help! :)

B- the rash is NME
 
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Jul 9, 2014
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42 yo. pt. admitted with a piece of meat lodged in the lower esophagus. With difficulty, the meat was removed with esophagoscopy. In the evening, he develops a 101F fever. Next diagnostic study?

A) CT of chest.
B) Lateral x-rays of neck.
C) MRI of chest.
D) Repeated esophagoscopy.
E) Water- soluble contrast upper GI study.

Could really use the help....

E. You're worried about a perforation
 
Jan 23, 2016
1
0
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  1. Medical Student
26.
A 67-year-old postal worker comes to the physician 1 day after a 5-minute episode of weakness and numbness in his right (dominant) hand while at work. He did not have visual problems, headache, or weakness or numbness of the lower extremities. He is currently asymptomatic. He has smoked one pack of cigarettes daily for 45 years. He has not seen a physician in 40 years. His pulse is 85/min and irregular, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Pulses are palpable. Carotid bruits are heard bilaterally. Heart sounds are normal except for frequent premature beats. Neurologic examination shows no abnormalities. An ECG shows a normal sinus rhythm with multiple atrial premature contractions. Which of the following is the most appropriate next step in management?
A
Echocardiography
B
Carotid duplex ultrasonography
C
Heparin therapy
D
Tissue plasminogen activator therapy
E
Warfarin therapy
 

Bluefunk

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Jun 4, 2010
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26.
A 67-year-old postal worker comes to the physician 1 day after a 5-minute episode of weakness and numbness in his right (dominant) hand while at work. He did not have visual problems, headache, or weakness or numbness of the lower extremities. He is currently asymptomatic. He has smoked one pack of cigarettes daily for 45 years. He has not seen a physician in 40 years. His pulse is 85/min and irregular, and blood pressure is 140/90 mm Hg. The lungs are clear to auscultation. Pulses are palpable. Carotid bruits are heard bilaterally. Heart sounds are normal except for frequent premature beats. Neurologic examination shows no abnormalities. An ECG shows a normal sinus rhythm with multiple atrial premature contractions. Which of the following is the most appropriate next step in management?
A
Echocardiography
B
Carotid duplex ultrasonography
C
Heparin therapy
D
Tissue plasminogen activator therapy
E
Warfarin therapy


Late to the party here but for those who find this thread - B carotid duplex ultrasonography. Vignette describes TIA. Bruit suggests carotid stenosis - duplex ultrasound to confirm and assess need for carotid enarterectomy.
 
Feb 18, 2014
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The alcoholic pancreatitis question. Ca is 7.7. Which is the most appropriate intravenous administration?

- calcium gluconate
- Ringer's lactate


I remember I got it right, but does not recall the answer! Any help? I guess Ringer's (fluid) is superior here. Any confirmation from people solved the question?
I picked Ca-gluconate and got it right
 
Oct 22, 2016
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I picked Ca-gluconate and got it right
I picked calcium gluconate and got it wrong mate. Answer is Ringer lactate. As per PRE TEST,Ringer lactate is the best fluid to replace GI losses of K and bicarb. This patient as been vomiting for the past 12 hrs. Replace fluid losses first.
 

doyouhaveaflag

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Nov 30, 2013
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Form 1:

1) What is the correct answer for the case of FAP? proctocolectomy with ilioanal resorvoir.
2) The case of (septicemia?) following diverticulitis surgery and seems inflamed afterward. What is the organism? I answered E.Coli but was wrong! Is it bacteroides?
3) The 52 yo woman with stippled calcifications on mammogram. No palpable masses. Next step? FNA was wrong! What is correct answer?
4) A kid with linear temporal skull fracture. What is the finding on CT? There were all types of cranial hemorrhages and meningitis. Did not really understand the question!
5) Nephrolithiasis case. Asking what is the finding on UA? WBC was a choice but it was normal. Is "RBC cells " the correct answer?
6) CRF case undergoing elective cholecystectomy asking what do you need to correct before the surgery! She has high K and PO4, PH 7.3. Really did not understand it!
7) Case of aortic rupture. Asking what to do? I picked exploratory thoracotomy but was wrong!! C'mon!!
8) Fluid replacement for burns case. Is the clue Parkland formula? Is it 15 L Ringer's lactate? (9.5L was wrong)

9) AV fistula case. I answered it PE. But seems the correct high output congestive heart failure. But c'mon! does this really happen is just 24 hours!! Seriously!!

10) The guy with bullet in his calf. I answered it wound irrigation and was wrong!
I know this is an old thread, but I thought I'd answer a few for people searching around for the correct answers (as I was when I found this). Most of these have already been answered. I note down my answers as I go so I can see which ones I got right as well as the incorrects.

2: C. perfringens. The key here is the crepitus around the colostomy site. Clostridium perfringens is a classic gas producing bug, so I picked it and got it right.

5: RBCs (I think the answer said 30 RBCs/hpf). Kidney stones are sharp little buggers and frequently cause a bit of bleeding in the urinary tract as they come out. Hence, you see blood in the UA.
 
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doyouhaveaflag

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I picked Ca-gluconate and got it right
I picked calcium gluconate and got it wrong mate. Answer is Ringer lactate. As per PRE TEST,Ringer lactate is the best fluid to replace GI losses of K and bicarb. This patient as been vomiting for the past 12 hrs. Replace fluid losses first.
There were two different questions asking you to pick between calcium gluconate and LR. Dochm is probably thinking of the one where a woman had a parathyroid adenoma removed and then the patient had symptomatic hypocalcemia afterwards (perioral tingling). The correct answer on that one was calcium gluconate.

Hyperenigma is right on the LR for the pancreatitis one. The patient was hypovolemic and needed fluid resuscitation as next best step.
 

Jay2910

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Dec 13, 2011
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For the question regarding a 1 year old boy, with persistent cough, and a rash . . .why did you guys pick VIPoma? I don't see any mention of persistent cough, and a rash in Harrison's ... . help would be much appreciated!
 
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