Surgery NBME 4 qs

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MudPhud20XX

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So these are q from surgery NBME 4 that I would like to get some help:

1. an obese 72 y/o male came to ER 15 min after he collapsed at home. his wife says he has had upper abdomnial pain, nausea, vomiting for the past 24 hours. he has HTN, coronary artery dz. He is diaphoretic. temp is 36.5C, pulse is 115, resp rate 22, palpable systolic bp is 80. no JVD, lungs clear, no murmurs, no gallops. abdomen is tender. pul artery cath shows

cardiac index: 1.2 (N: 2.5-4.2)
mean pul arterial pressure: 5 (N: 9-16)
pul. capillary wedge pressure: 1 (N: 5-16)
systemic vascular resistance: 1929 (N: 770-1500)

which is the predominant type of shock in this pt?

A. anaphylactic
B. cardiogenic
C. hypovolemic
D. neurogenic
E. septic
--> So I chose B due to the low cardiac index but it was wrong. I am now thinking either C or E. So if it was cardiogenic the wedge pressure should have been high right?

2. 65 y/o female came to ER 1 hour after she fell. she has right wrist pain, her last doctor's visit was 10 yrs ago, exam shows swelling/tenderness of the Rt. wrist. x-ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca2+ is 12.4, serum creatinine is 1.2, which of the following serum conc is most likely to be decreased in this pt?

A. 1,25 dihydroxycholecalciferol
B. magnesium
C. parathyroid hormone
D. phosphorus
E. vitamin C
--> So I chose C and was wrong, is it then D? what is the significance of "subperiosteal bone resorption is noted in the distal phalanges?"

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So these are q from surgery NBME 4 that I would like to get some help:

1. an obese 72 y/o male came to ER 15 min after he collapsed at home. his wife says he has had upper abdomnial pain, nausea, vomiting for the past 24 hours. he has HTN, coronary artery dz. He is diaphoretic. temp is 36.5C, pulse is 115, resp rate 22, palpable systolic bp is 80. no JVD, lungs clear, no murmurs, no gallops. abdomen is tender. pul artery cath shows

cardiac index: 1.2 (N: 2.5-4.2)
mean pul arterial pressure: 5 (N: 9-16)
pul. capillary wedge pressure: 1 (N: 5-16)
systemic vascular resistance: 1929 (N: 770-1500)

which is the predominant type of shock in this pt?

A. anaphylactic
B. cardiogenic
C. hypovolemic
D. neurogenic
E. septic
--> So I chose B due to the low cardiac index but it was wrong. I am now thinking either C or E. So if it was cardiogenic the wedge pressure should have been high right?

2. 65 y/o female came to ER 1 hour after she fell. she has right wrist pain, her last doctor's visit was 10 yrs ago, exam shows swelling/tenderness of the Rt. wrist. x-ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca2+ is 12.4, serum creatinine is 1.2, which of the following serum conc is most likely to be decreased in this pt?

A. 1,25 dihydroxycholecalciferol
B. magnesium
C. parathyroid hormone
D. phosphorus
E. vitamin C
--> So I chose C and was wrong, is it then D? what is the significance of "subperiosteal bone resorption is noted in the distal phalanges?"

1. In cardiogenic shock we will see increased mean pul arterial pressure and pul. capillary wedge pressure along with decreased cardiac index. Pt has had nausea, vomiting for the past 24 hours, results of cardiac cath show low volume, so it's hypovolemic shock. In septic shock systemic vascular resistance will be decreased.
2. Subperiosteal bone resorption is the most consistent and specific finding of hyperparathyroidism and is virtually pathognomonic of the condition.
 
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a healthy 14 yo boy came to physician for a 2 wk hx of severe Rt. knee pain and hip associated with limp. he has intermittent, mild pain in the same knee and hip for 3 months. he plays on his junior high school football team. he is at the 50th percentile for height and greater than the 95th percentile for weight. temp is 37C. abduction of the Rt. hip is slightly dec compared with the Lt. there is mild tenderness of the Rt. hip. exam of the Lt. hip shows no abnormalities. he walks with a limp and is unable to bear his full weight on the Rt.

A. legg calve perthes dz
B. osgood schlatter dz
C. osteomyelitis
D. recurrent sprain
E. septic arthritis
F. slipped capital femoral epiphysis
G. stress fracture
H. tibia vara
I. toxic synovitis

I was pretty sure that B was the right answer. It was wrong. I thought this was a classic OSD with an athletic teen story, but it's apparently not. Any thoughts?
 
1. In cardiogenic shock we will see increased mean pul arterial pressure and pul. capillary wedge pressure along with decreased cardiac index. Pt has had nausea, vomiting for the past 24 hours, results of cardiac cath show low volume, so it's hypovolemic shock. In septic shock systemic vascular resistance will be decreased.
2. Subperiosteal bone resorption is the most consistent and specific finding of hyperparathyroidism and is virtually pathognomonic of the condition.
so for #2,

65 y/o female came to ER 1 hour after she fell. she has right wrist pain, her last doctor's visit was 10 yrs ago, exam shows swelling/tenderness of the Rt. wrist. x-ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca2+ is 12.4, serum creatinine is 1.2, which of the following serum conc is most likely to be decreased in this pt?

A. 1,25 dihydroxycholecalciferol
B. magnesium
C. parathyroid hormone
D. phosphorus
E. vitamin C

I chose C but still got it wrong. any idea? thanks!
 
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so for #2,

65 y/o female came to ER 1 hour after she fell. she has right wrist pain, her last doctor's visit was 10 yrs ago, exam shows swelling/tenderness of the Rt. wrist. x-ray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. her serum Ca2+ is 12.4, serum creatinine is 1.2, which of the following serum conc is most likely to be decreased in this pt?

A. 1,25 dihydroxycholecalciferol
B. magnesium
C. parathyroid hormone
D. phosphorus
E. vitamin C

I chose C but still got it wrong. any idea? thanks!

The questions asks what's decreased. Which of those is decreased in hyperparathyroidism
 
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F
a healthy 14 yo boy came to physician for a 2 wk hx of severe Rt. knee pain and hip associated with limp. he has intermittent, mild pain in the same knee and hip for 3 months. he plays on his junior high school football team. he is at the 50th percentile for height and greater than the 95th percentile for weight. temp is 37C. abduction of the Rt. hip is slightly dec compared with the Lt. there is mild tenderness of the Rt. hip. exam of the Lt. hip shows no abnormalities. he walks with a limp and is unable to bear his full weight on the Rt.

A. legg calve perthes dz
B. osgood schlatter dz
C. osteomyelitis
D. recurrent sprain
E. septic arthritis
F. slipped capital femoral epiphysis
G. stress fracture
H. tibia vara
I. toxic synovitis

I was pretty sure that B was the right answer. It was wrong. I thought this was a classic OSD with an athletic teen story, but it's apparently not. Any thoughts?

Fat teen with knee/hip pain = SCFE
 
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A 42-*year*-old construction worker is brought to the emergency department 20 minutes after falling 30 feet from a scaffold. En route to the hospital, he received 1 L of lactated Ringer solution. On arrival, he is awake and alert and has severe abdominal and leg pain. He can move all extremities. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 16/min, and blood pressure is 120/70 mm Hg. Examination shows ecchymoses over the left forehead and lower abdomen. There is an obvious deformity of the left lower extremity. There is no neck tenderness. Cardiopulmonary examination shows no abnormalities. The lower abdomen is slightly distended and exquisitely tender. There is no blood at the urethral meatus. Rectal examination shows no abnormalities. Insertion of a urinary catheter yields 30 mL of grossly bloody fluid. An additional 1.5 L of lactated Ringer solution is administered, and the left lower extremity is placed in traction. Thirty minutes later, his pulse is 95/min, and blood pressure is 140/80 mm Hg. No additional urine has drained from the catheter. Which of the following is the most likely cause of this patient's anuria?

A) Acute tubular necrosis
B) Hypovolemia
C) Rupture of the bladder
D) Syndrome of inappropriate secretion of ADH (vasopressin)
E) Transection of the urethra
--> So I am leaning toward C, but why not E?


A 67 year old man is brought to the physician because of severe pain in the right foot for 6 hours. On examination the right foot is pale and cool and pedal pulse are not palpable, he can wiggle his toes. Examination of the left foot shows no abnormalities. There are bilateral femoral pulses and pulsatile mases in the popliteal fossae. Which of the following is the most appropriate next step in diagnosis?
a) Cardiolipin Antibody essay
b) Measurement of transcutaneous oxygenation in the feet
c) Measurement of serum antithrombin III concentration
d) Impedance plethysmography
e) Arteriography with runoff
f) Venography of the right lower extremity
--> So is this is a compartment syndrome? I am leaning toward going for E, but not really sure, any thoughts?
 
A previously healthy 37-year-old woman comes to the physician because of a 2-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37°C (98.6°F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 x 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?
A) Measurement of serum a-fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan
D) MRI of the liver
E) Fine-needle aspiration biopsy of the mass
F) No further testing is indicated

Any thoughts? I am leaning toward E.


An 87-year-old woman is brought to the emergency department from a skilled nursing care facility because of six episodes of loose brown stools daily during the past week. There is no visible blood or mucus in the stool, and she has not had fever or abdominal pain. Five years ago, she sustained a cerebral infarction and has residual left hemiparesis. She has atrial fibrillation and multiple compression fractures from osteoporosis. Her medications include warfarin, digoxin, and famotidine. One month ago, she began taking acetaminophen with codeine for her most recent compression fracture. Her temperature is 37.1°C (98.8°F), pulse is 80/mm and irregular, respirations are 16/mm, and blood pressure is 130/75 mm Hg. Abdominal examination shows mild tenderness in the left lower quadrant. Bowel sounds are normal. Rectal examination shows normal tone with hard stool in the vault. Test of the stool for occult blood is negative. An abdominal x-ray shows copious stool throughout the bowel. There is no evidence of free air or obstruction. Which of the following is the most appropriate next step in management?
A) Elevation of the head of the bed during sleep
B) Elimination of milk from the diet
C) Elimination of spicy food from the diet
D) Enemas
E) Esophagogastroduodenoscopy
F) Left hemicolectomy
G) Low-fat diet
H) Mesenteric angiography
I) Omeprazole therapy
J) Recommendation to increase her milk consumption
K) Stress management
L) Total proctocolectomy
M) Ultrasonography of the abdomen
N) Upper gastrointestinal series
--> so this is ischemic colitis right? So H? Any thoughts?
 
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A previously healthy 37-year-old woman comes to the physician because of a 2-month history of intermittent, right upper abdominal pain that usually occurs after meals. She has not had fever, chills, vomiting, nausea, weight loss, or change in bowel movements. She takes no medications. Her temperature is 37°C (98.6°F), pulse is 68/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Examination shows no jaundice or scleral icterus. Abdominal examination shows no abnormalities. Her leukocyte count is 5000/mm3. Results of liver function tests are within the reference ranges. Abdominal ultrasonography shows a thickened gallbladder wall, cholelithiasis, and a 4.2-cm hepatic mass in the right lobe. An abdominal CT scan shows the mass to be 4.2 x 3.5 cm with a central scar. Which of the following is the most appropriate next step in diagnosis?
A) Measurement of serum a-fetoprotein concentration
B) Hepatitis B virus serology
C) Radionuclide liver scan
D) MRI of the liver
E) Fine-needle aspiration biopsy of the mass
F) No further testing is indicated

Any thoughts? I am leaning toward E.


An 87-year-old woman is brought to the emergency department from a skilled nursing care facility because of six episodes of loose brown stools daily during the past week. There is no visible blood or mucus in the stool, and she has not had fever or abdominal pain. Five years ago, she sustained a cerebral infarction and has residual left hemiparesis. She has atrial fibrillation and multiple compression fractures from osteoporosis. Her medications include warfarin, digoxin, and famotidine. One month ago, she began taking acetaminophen with codeine for her most recent compression fracture. Her temperature is 37.1°C (98.8°F), pulse is 80/mm and irregular, respirations are 16/mm, and blood pressure is 130/75 mm Hg. Abdominal examination shows mild tenderness in the left lower quadrant. Bowel sounds are normal. Rectal examination shows normal tone with hard stool in the vault. Test of the stool for occult blood is negative. An abdominal x-ray shows copious stool throughout the bowel. There is no evidence of free air or obstruction. Which of the following is the most appropriate next step in management?
A) Elevation of the head of the bed during sleep
B) Elimination of milk from the diet
C) Elimination of spicy food from the diet
D) Enemas
E) Esophagogastroduodenoscopy
F) Left hemicolectomy
G) Low-fat diet
H) Mesenteric angiography
I) Omeprazole therapy
J) Recommendation to increase her milk consumption
K) Stress management
L) Total proctocolectomy
M) Ultrasonography of the abdomen
N) Upper gastrointestinal series
--> so this is ischemic colitis right? So H? Any thoughts?

For the first one...first ask yourself what liver mass has a central stellate scar. Then go from there.

For the second one. Ischemic colitis presents with bloody diarrhea after a hypotensive episode or AAA repair, and is diagnosed with CT followed by scope. You may be thinking of acute mesenteric ischemia, but notice that she IS on warfarin. Unless they tell you she is subtherapeutic, that's not where they're going with that one. They also didn't give the "pain out of proportion". So try backing up and dissecting the question again. Note her recent medication change and her rectal exam.

Figured this would be more helpful in the long run than just telling you the answers!
 
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For the first one...first ask yourself what liver mass has a central stellate scar. Then go from there.

For the second one. Ischemic colitis presents with bloody diarrhea after a hypotensive episode or AAA repair, and is diagnosed with CT followed by scope. You may be thinking of acute mesenteric ischemia, but notice that she IS on warfarin. Unless they tell you she is subtherapeutic, that's not where they're going with that one. They also didn't give the "pain out of proportion". So try backing up and dissecting the question again. Note her recent medication change and her rectal exam.

Figured this would be more helpful in the long run than just telling you the answers!
Thanks man, so with central scar it's probably saying that this is focal nodular hyperplasia so I guess the answer would be no further testing needed. right? For the 2nd one, so I will go with enemas to just take out that hard stools, dang so much red herring with these NBME qs, but thanks a lot man!
 
A previously healthy 25-*year-*old woman is brought to the emergency department 20 minutes after being struck by an automobile. On arrival, she has pelvic and left lower extremity pain. Her temperature is 36.8°C (98.3°F), pulse is 135/min, respirations are 26/min, and blood pressure is 90/48 mm Hg. Examination shows an unstable pelvis and an obvious deformity of the left thigh. X-*rays show fractures of the left iliac wing and left midshaft femur. Ten units of packed red blood cells are administered, and her blood pressure stabilizes. Nine days after operative repair of her fractures, she develops jaundice. Abdominal examination shows no abnormalities. Serum studies show:

Bilirubin, total 5 mg/dL
Direct 2.3 mg/dL
Alkaline phosphatase 150 U/L
γ*-Glutamyltransferase 35 U/L (N=5–50)


Which of the following is the most likely underlying cause of these findings?
A) Decreased excretion of bilirubin into the bile
B) Decreased hepatic conjugation of bilirubin
C) Decreased hepatic uptake of bilirubin
D) Obstruction of common bile duct
E) Overproduction of bilirubin
--> so what the heck is going on with her? what can cause mixed hyperbilirubinemia after the femur surgery?
 
Thanks man, so with central scar it's probably saying that this is focal nodular hyperplasia so I guess the answer would be no further testing needed. right? For the 2nd one, so I will go with enemas to just take out that hard stools, dang so much red herring with these NBME qs, but thanks a lot man!

Nailed it!
 
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