Official Surgery Shelf Exam Discussion Thread

[VisionaryTics]

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[cpeters1]

Hey guys, surgery is my first rotation - would it be a good idea to read step up to medicine since I haven't had internal med or any other rotation yet? Or should I stick to Uworld/Pestana/just surgery books? Thanks! And sorry for the inappropriate post location, but I think this thread is more frequented than the other ones I've seen...

Definitely read step up to medicine. Take to heart when people say surgery is mostly internal medicine, as far as the shelf exams go. I learned that part the hard way.

My approach would be to read pestana and get a feel for the systematic approach to the questions (i.e. pt presents with ____, what is the most appropriate/what to do next/likely diagnosis/etc). This will help with timing on the test and make pulling out the important points in a question stem second nature. It will also give you a chance to step back and look at the whole patient to see what points they are trying to connect for you. There is a lot of extraneous material there to throw you off, so the faster you get at seeing the patterns of pertinent info (age, time course, labs, imaging, etc.), the better off you'll be. It just takes practice, persistence, and patience.

As you do UWorld/Kaplan/pretest/whatever, read up on things you aren't familiar with in step up/essentials of surgery. Supplement with case files for a change of pace to get the clinical feel of how to flow through algorithms.

And don't forget the immortal words of Goljan, "the more you read, the more you know. It's as simple as that."

 

[operaman]

Kaplan's Step 2 CK surgery videos are Pestana reading and discussing his vignettes

 

[Dr.Nick Riviera]

I have this rotation second after family medicine, so am planning to use that "down" time to review Step Up/UW/MKSAP to brush up on the med questions.

Has anyone here use the onlinemeded videos to prepare for this shelf? I saw there was some stuff on surgery and was wondering if people had found it worth the investment in time.

 

[elegantorchid]

Got back score. 71 (assuming its raw)

Just used kaplan 2x without videos. Pestana talks sooo slow. Did Uworld questions and about 1/5 Kaplan questions. Really didn't like kaplan questions. felt like they presented cases weird and mess up your confidence when you are approached with a classic presentation making you second guess yourself thinking but what if????

The exam had surgery style questions like pestana presents them but there was as some ppl said loads of random IM in it as well.

I'm not particularly happy with my score since I think its just avg. I thought I studied pretty hard :/ Any body know anything about the scoring system?

 

[swoopyswoop]

Shelf on Friday.

I have read Pestana x 1, Case Files (almost done), NMS Casebook (almost done), UWorld surgery Qs (almost done).

What else should I do? I haven't had internal med yet. Should I start doing random blocks of IM questions on uworld?

 

[mybubbles627]

Is NMS Casebook still relevant since its form 2002? I have surgery for my next rotation and am trying to decide what books to get for it.

Pestena
Surgical Recall
NMS? Casebook vs Textbook?
Pre-Test?
Clinical Cases?
U-World

 

[Fatalis]

just starting my surgery rotation, what are the good books to read?
I got a copy of lawerence, surgery recall and pestana notes [small notebook]. anything else?

 

[Canadianmedstudent]

Had the NBME in early Aug 2014, score: 99. Did Pestana's (Kaplan book) x2, pre-test 2013 x2, NMS Casebook x1, UWorld surgery x2, and selected UWorld medicine questions (GI, hepato, fluids, ENT, endocrine, optho, pulmonary). Despite people slagging Pre-test, found the answer explanations useful and the difficulty of the questions good for test preparation. At minimum, do Pestana's and UWorld. NMS Casebook was less helpful I found.

 

[Freddie Mercury]

Just had my shelf yesterday. No joke, it really did feel like medicine+ob+peds, moreso than surgery, as so many people here mentioned. Pestana notes definitely helped with what surgery there was on the exam, and in at least attempting to reason through some of the less surgery-ish questions. I did NMS casebook but don't recall much of that being helpful for the exam, and UWorld was just *ok*. If I could go back in time I would probably add pre-test to the regimen, and maybe some UWorld med Qs. My exam felt pretty light on trauma, and heavy on ortho.

Good luck everyone.

 

[Coffee dude]

few questions from the practice shelf...answers and WHY would be greatly appreciated!
1.
46 y/o man with chronic alcoholism comes to ED b/c of 12h history of n/v and midabdominal pain that radiates to the back. HR 120/min, RR 20/min, BP 110/60. Abdominal examination shows tenderness to palpation over the upper quadrants. Bowel sounds are absent. Lab studies show:
Hgb 10.1 g/dL
WBC 24,500
Plt 810,000
Serum
-amylase: 1842 U/L
-albumin: 4.1 g/dL
-Ca: 7.7
Blood glc 248

The most appopropriate next step is IV administration of
a) atropine, b) Calcium gluconate, c) cimetidine, d) imipenem, e) lactated ringer solution

2.
36hr after admission to hospital for evaluation of mild-mod diffuse abdominal pain, a 42 y/o woman remains obstipated despite treatment with multiple laxatives. Her last bowel movement was 6d ago. 9 yr history of scleroderma and chronic constipation. 1y history progressive abdominal distention. Current temp is 100.4 *F, HR 110/min, RR 22/min, BP 110/60. Abdomen is distended and tympanitic with diffuse tenderness to deep palpation. There is involuntary guarding and rebound. Hgb is 12 g/dL, and leukocyte count is 14,000. AXR shows dilation of the colon and 12-cm cecum. No distention of small bowel. Which is the most appropriate next step in management?
a) Metoclopramide therapy, b) octreotide therapy, c) colonoscopy, d) sigmoidoscopy, e) laparotomy

3.
1 y/o boy brought to physician because of persistent cough, loose stools, and facial rash for 2 mo. He has had a 1.8 kg weight loss during this period and is currently at the 50th percentile for length and 20th for weight. Appetite and activity remain normal, no hx of fever. Temp is 98.6 *F, HR 100/min, RR 18/min, BP is 80/50 mmHg. Examination shows a malr flush and abdominal distention. CT scan of abdomen shows a small tumor localized to pancreas. The tumor is surgically removed and the patient recovers uneventfully. Which of the following is most likely dx?
a) insulinoma, b) glucagonoma, c) neuroblastoma, d) pancreatic pseudocyst, e) VIP-secreting tumor

4.
67 y/o postal worker comes to physican 1 day after 5m episode of weakness and numbness in R hand while at work. Didn't have any visual problems, headache, or weakness/numbness in LE. Currently asymptomatic. Has smoked 1 PPD x45yrs. Not seen a physician in 40y. HR 85 and irregular, BP is 140/90. Lungs CTAB, pulses palpable. Carotid bruits are heart b/l. Heart sounds are normal except for frequent premature beats. Neurologic examination shows no abnormalities. An ECG shows a NSR with multiple PAC. Which of following is most appopriate next step?
a) Echo, b) carotid duplex U/S, c) heparin therapy, d) TPA therapy, e) warfarin therapy

5.
12h after undergoing drainage of pancreatic abscess, 52 yoM with alcholism becomes bradycardic and hypoxic and requires intubation and mechanical ventilation. Weighs 70kg. Ventilator is set at an FiO2 of 100%, tidal volume of 1000 mL, and positive end-expiratory pressure of 2.5cm H2O. Arterial blood gas analysis shows:
pH 7.36
PCO2 40 mmHg
PO2 48 mmHg
Which is most appropriate next step?
a) begin IV acetazolamide therapy, b) begin IV furosemide therapy, c) begin IV heparin therapy, d) begin IV sodium bicarb, e) begin IC urokinase, f) Decrease FiO2, g) decrease tidal volume, h) increase PEEP, i) increase tidal volume

 

[VisionaryTics]

few questions from the practice shelf...answers and WHY would be greatly appreciated!
1.
46 y/o man with chronic alcoholism comes to ED b/c of 12h history of n/v and midabdominal pain that radiates to the back. HR 120/min, RR 20/min, BP 110/60. Abdominal examination shows tenderness to palpation over the upper quadrants. Bowel sounds are absent. Lab studies show:
Hgb 10.1 g/dL
WBC 24,500
Plt 810,000
Serum
-amylase: 1842 U/L
-albumin: 4.1 g/dL
-Ca: 7.7
Blood glc 248

The most appopropriate next step is IV administration of
a) atropine, b) Calcium gluconate, c) cimetidine, d) imipenem, e) lactated ringer solution

E. This patient has severe pancreatitis. The systemic inflammation causes massive third-spacing of intravascular volume, evidenced here by tachycardia. Replace volume with LR.

2.
36hr after admission to hospital for evaluation of mild-mod diffuse abdominal pain, a 42 y/o woman remains obstipated despite treatment with multiple laxatives. Her last bowel movement was 6d ago. 9 yr history of scleroderma and chronic constipation. 1y history progressive abdominal distention. Current temp is 100.4 *F, HR 110/min, RR 22/min, BP 110/60. Abdomen is distended and tympanitic with diffuse tenderness to deep palpation. There is involuntary guarding and rebound. Hgb is 12 g/dL, and leukocyte count is 14,000. AXR shows dilation of the colon and 12-cm cecum. No distention of small bowel. Which is the most appropriate next step in management?
a) Metoclopramide therapy, b) octreotide therapy, c) colonoscopy, d) sigmoidoscopy, e) laparotomy

E. Bowel obstruction refractory to medical management, now with signs of peritoneal inflammation (guarding, rebound). FYI, the answer is almost always laparotomy when peritoneal signs are present.

3.
1 y/o boy brought to physician because of persistent cough, loose stools, and facial rash for 2 mo. He has had a 1.8 kg weight loss during this period and is currently at the 50th percentile for length and 20th for weight. Appetite and activity remain normal, no hx of fever. Temp is 98.6 *F, HR 100/min, RR 18/min, BP is 80/50 mmHg. Examination shows a malr flush and abdominal distention. CT scan of abdomen shows a small tumor localized to pancreas. The tumor is surgically removed and the patient recovers uneventfully. Which of the following is most likely dx?
a) insulinoma, b) glucagonoma, c) neuroblastoma, d) pancreatic pseudocyst, e) VIP-secreting tumor

E. VIPoma. Giveaway is facial flushing and diarrhea.

4.
67 y/o postal worker comes to physican 1 day after 5m episode of weakness and numbness in R hand while at work. Didn't have any visual problems, headache, or weakness/numbness in LE. Currently asymptomatic. Has smoked 1 PPD x45yrs. Not seen a physician in 40y. HR 85 and irregular, BP is 140/90. Lungs CTAB, pulses palpable. Carotid bruits are heart b/l. Heart sounds are normal except for frequent premature beats. Neurologic examination shows no abnormalities. An ECG shows a NSR with multiple PAC. Which of following is most appopriate next step?
a) Echo, b) carotid duplex U/S, c) heparin therapy, d) TPA therapy, e) warfarin therapy

Hmm, I would say B. I think the afib is a distractor. Patient had a TIA, likely carotid stenosis.

5.
12h after undergoing drainage of pancreatic abscess, 52 yoM with alcholism becomes bradycardic and hypoxic and requires intubation and mechanical ventilation. Weighs 70kg. Ventilator is set at an FiO2 of 100%, tidal volume of 1000 mL, and positive end-expiratory pressure of 2.5cm H2O. Arterial blood gas analysis shows:
pH 7.36
PCO2 40 mmHg
PO2 48 mmHg
Which is most appropriate next step?
a) begin IV acetazolamide therapy, b) begin IV furosemide therapy, c) begin IV heparin therapy, d) begin IV sodium bicarb, e) begin IC urokinase, f) Decrease FiO2, g) decrease tidal volume, h) increase PEEP, i) increase tidal volume

H. ABG shows patient is hypoxemic. 2 ways to increase PO2 are increasing FiO2 (already at 100%) and increasing PEEP. Peep of 2.5 is pretty low, so you've got some room to maneuver. As an aside, tidal volume of 1000 for 70kg man is way high, especially for likely ARDS (which you usually treat with low tidal volume/increased PEEP ventilation). But monkeying with tidal volume will not correct the patient's hypoxemia.

As above.

 

[Coffee dude]

As above.

Thanks so much.

About the afib one...I understand why you'd Carotid DUS him, but...

^why would this algorithm not be indicated and medical therapy prescribed?

 

[VisionaryTics]

Thanks so much.

About the afib one...I understand why you'd Carotid DUS him, but...

^why would this algorithm not be indicated and medical therapy prescribed?

Well that algorithm would not be indicated because you have no idea when this afib started, and you have to assume it is chronic. That means aspirin or warfarin depending on CHADS2 score.

However, this question is asking you to diagnose and manage the cause of this guy's TIA, which is likely carotid stenosis. Let's say the guy had 99% carotid stenoses bilaterally...you need to operate and anticoagulating the guy is just going to delay the operation he needs.

 

[wololololololo]

Definitely read step up to medicine. Take to heart when people say surgery is mostly internal medicine, as far as the shelf exams go. I learned that part the hard way.

My approach would be to read pestana and get a feel for the systematic approach to the questions (i.e. pt presents with ____, what is the most appropriate/what to do next/likely diagnosis/etc). This will help with timing on the test and make pulling out the important points in a question stem second nature. It will also give you a chance to step back and look at the whole patient to see what points they are trying to connect for you. There is a lot of extraneous material there to throw you off, so the faster you get at seeing the patterns of pertinent info (age, time course, labs, imaging, etc.), the better off you'll be. It just takes practice, persistence, and patience.

As you do UWorld/Kaplan/pretest/whatever, read up on things you aren't familiar with in step up/essentials of surgery. Supplement with case files for a change of pace to get the clinical feel of how to flow through algorithms.

And don't forget the immortal words of Goljan, "the more you read, the more you know. It's as simple as that."

Are there any specific chapters in Step Up that you think are important? Surgery is my first shelf and the whole IM thing is making me anxious. I've skimmed the thread and people have mentioned Fluids/electrolytes & GI as good chapters to read.

 

[operaman]

Thanks so much.

About the afib one...I understand why you'd Carotid DUS him, but...

^why would this algorithm not be indicated and medical therapy prescribed?

In addition to what VT said, patient in the vignette doesn't have Afib, or at least didn't when they did the EKG. NSR and PACs is not afib. They just wrote the distractors in a mean way to sucker people down that road. Really they handed it over on a silver platter: TIA, no afib, +carotid bruits = duplex and probably a CEA soon to follow.

 

[VisionaryTics]

In addition to what VT said, patient in the vignette doesn't have Afib, or at least didn't when they did the EKG. NSR and PACs is not afib. They just wrote the distractors in a mean way to sucker people down that road. Really they handed it over on a silver platter: TIA, no afib, +carotid bruits = duplex and probably a CEA soon to follow.

True, I didn't read that. I just saw irregular pulse.

This is straightforward question, then.

 

[Longhorn91]

Well, shoot, I got a 65 raw. Did Pestana's twice, Uworld surg once+GI+Fluids and electrolytes, NMS cases once. It was my first rotation. Whatever, I f***in hated surgery anyways. Surgeons always act way smarter than everyone else, when everyone knows they're not. Good riddance.

 

[Coffee dude]

Well, shoot, I got a 65 raw. Did Pestana's twice, Uworld surg once+GI+Fluids and electrolytes, NMS cases once. It was my first rotation. Whatever, I f***in hated surgery anyways. Surgeons always act way smarter than everyone else, when everyone knows they're not. Good riddance.

This post is hilarious.

"ugh they think they're so smart"

Gets 65 on their exam.

 

[Dave89]

This post is hilarious.

"ugh they think they're so smart"

Gets 65 on their exam.

I don't know what 65 raw means (65%?), but taking the Surgery shelf first sucks by all accounts.

 

[bypass123]

Scaled Score 92
Percentile 98

Fairly relaxed surgery rotation, didn't learn too much shelf relevant material on rotation.
50-60% IM, 30% Surgery, 10-20% Other (Peds, OB, etc).
UWorld Surgery. Good as always, 7-8 questions that were nearly identical.
Kaplan Qbank Surgery/ER/GI/Heme/Nephro. (Recommended)
USMLERx IM(400Qs)+Surgery. (Good Resource)
Pestana videos/notes (2x). (Good Resource)

 

[WilburSK]

Does anyone have a suggestion for the best pestana surgery flashcard set online?

 

[drake19]

edit

 

[DrShazam]

87 scaled, which corresponds to 92nd percentile. Like everyone else, I came out of the exam thinking I had failed it or maybe narrowly passed because of how difficult it was. It didn't feel like much of medicine or surgery, and it was so incredibly broad that I am not sure what could've helped me prepare better.

To prepare:
1. Read all of Surgical Recall (useless waste of time, highly regret this)
2. Did ~300 questions in Pretest (highly recommend, wish I had completed all of it)
3. Did both NBME Surgery exams (highly recommend; I got a 69 three days before and 72 the night before the exam, and so you can imagine why I thought I had bombed my shelf. It made me realize I was rushing too much, and that helped me slow down a lot more so I wouldn't lose easy points on the real deal)
4. Read my Step up to Medicine notes the night before (not sure if it ended up making a difference since my exam felt nothing like the medicine shelf did; scored an 87 on the medicine shelf as well, and had only had medicine before surgery)
5. Read Pestana x2 (Highly recommend, had some questions on the NBME practice shelves that were directly from it)

Looking back, I would probably read NMS casebook instead of Surgical Recall. I would've also attempted UWorld since I think that could've helped me break 90, but for right now, I am pretty satisfied with my score.

Hope this helps 🙂

Final surgery grade: A

 

[metukah]

Any idea how many questions you need to get right to pass? I believe my school requires a score of "70"...what percentage does that equate to usually?

 

[operaman]

Any idea how many questions you need to get right to pass? I believe my school requires a score of "70"...what percentage does that equate to usually?

I'm not sure I've ever seen that data clearly stated. There's a lot of confusion among students regarding how shelves are scored as many conflate "raw" and "scaled" scores as well as "percentiles" and "percent correct."

My guess is you can miss quite a few. I'm usually good at calculating this sort of thing, but surgery was my first shelf and I felt very ambiguous about a LOT of questions. Was shocked to have scored so well on it; part of me still thinks there was an error in my favor but I'm not digging into it!

If I had to guess, I'd say 60 +/- 5 out of 100 correct probably equates to a scaled score of 70. I looked for an authoritative source last year but never did find one.

 

[metukah]

I'm not sure I've ever seen that data clearly stated. There's a lot of confusion among students regarding how shelves are scored as many conflate "raw" and "scaled" scores as well as "percentiles" and "percent correct."

My guess is you can miss quite a few. I'm usually good at calculating this sort of thing, but surgery was my first shelf and I felt very ambiguous about a LOT of questions. Was shocked to have scored so well on it; part of me still thinks there was an error in my favor but I'm not digging into it!

If I had to guess, I'd say 60 +/- 5 out of 100 correct probably equates to a scaled score of 70. I looked for an authoritative source last year but never did find one.

Thanks. Ya its actually my first shelf also so I was confused as to how thia actually worked. Appreciate the reply!

 

[sailormoon]

Raw score means # of correct answers out of 100 right??

 

[drake19]

edit

 

[metukah]

Anyone write the sirgery shelf today?? Mine was full of super long vignettes. Really dont know it went...

 

[operaman]

Raw score means # of correct answers out of 100 right??

Technically, yes it does. Most people do not use it that way or their schools use the wrong term. I see people posting raw scores of 99 -- no way anyone is only missing one question! What they mean is scaled score; scaled score of 99 is awesome but much more reasonable.

So, what is SHOULD BE:
Raw score = absolute # correct /100
Scaled score = standardized score designed to correct for differences in difficulty between exams standardized to a historic mean of 70. This is the score the NBME reports to the schools unless the school has requested some sort of exception where the NBME reports a true raw score.

 

[Dr. USMLE]

People actually can get 99 raw. It's even possible to get 100 scaled.


Radiology Resident
Step 1: 265+
Step 2: 265+
Step 3: 265+

 

[general admission]

How much effort would it take to get the 5th percentile? Would just going through Uworld surgery be enough to safely get there?

I assume 5th percentile is like the high 50s raw?

 

[moath roubi]

Case files surgery is the best book for surgery clerkship

 

[Handinhand]

How important is UWorld for the surgery shelf?

I'm just starting surgery and trying to get a hold on what I should be studying. I've already taken the Medicine shelf and scored a 90 without using UWorld (just MKSAP), so I'm wondering how helpful UWorld is for shelf exams? I ask because I wanted to hold off on buying it until step II studying comes along.

For resources right now I have:

Pestana
NMS Files
Surgical recall

Was looking for opinions also on Case Files and/or Pretest? Do you think it would add anything that the above will miss? I'll probably go through Step Up again for some of the more pertinent medicine blocks as well.

 

[Bojack Horseman]

80% --- not sure if percentile, raw, or scaled --- school did not specify

Just did uworld surgery and about 30% of pretest.

 

[Enzymes]

Any tips for the surgery shelf exam from recent test takers? Thanks!

 

[Bancrofti]

80% --- not sure if percentile, raw, or scaled --- school did not specify

Just did uworld surgery and about 30% of pretest.

No reading?

 

[Bojack Horseman]

No reading?

Sorry I forgot to mention I read pestana 1x and did most of the questions. If I had more time I would've liked to reread it and finish the questions. I also tried to watch the onlinemeded videos but I got bored after two or three of them.

 

[MrTambourineMan]

Case files surgery is the best book for surgery clerkship

Completely agree. Wish I would have found it before the last 2 weeks.

I only used pestana and case files (about half) and got >85 scaled. However, Did do well on medicine shelf immediately prior (better than on surgery).


Posted using SDN Mobile

 

[guitarguy23]

I'm using NMS Casebook since I've heard such great things, but I'm worried that it might be outdated. Has anyone done really well with this resource even though the most recent edition is from 2003?

 

[Cinclus]

Took surgery shelf about 2 weeks ago.
Score: 99

I read Pestana (the actual book, not just the notes pdf) and Case Files, both x 3. I did all of the surgery UWorld questions (not the most helpful thing ever) and made a document of questions I either could not answer or any info I thought would be good to remember, then I reviewed this document once the day before the shelf. I re-did all UWorld GI questions, about 15 endocrinology questions, and about 25 lytes + fluids questions. This was overkill, especially if you've had medicine previously. Know what "the next step" is for everything. Pestana will tell you all about the "next steps." I read about 80 pages of NMS Casebook early in the rotation, and the style wasn't to my liking. I love Case Files, and I have had success with this series time and again.

 

[Handinhand]

What surgery rotations are some of you on where you can read books 3 times? I feel like I barely have enough time to get through NMS, Pestana and UWorld once.

 

[abelabbot]

.

 

[abelabbot]

.

 

[filter07]

The ideal management is a core needle biopsy. However if that's not available, a needle localized open biopsy is a better answer. An FNA samples too little tissue and doesn't give you architectural details to make a diagnosis.

 

[abelabbot]

.

 

[filter07]

For 4 hours, a 55 year old male has acute intermittent pain that begins in right flank and radiates to right testicle. Most likely finding on Urinalysis? Why is the answer "Microscopic hematuria (RBC 30/hpf in sediment)" please explain

kidney stone

 

[abelabbot]

.

 

[abelabbot]

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