NBME SURGERY SHELF QUESTIONS
& CORRECT SOLUTIONS
A previosuly healthy 47 YOM comes in with 2 weeks of progressive abd swelling. PE
shows distention and shifting dullness, bowel sounds are normal. There is no
tenderness, masses or organomegaly. Paracentesis: 50ml milky chylous fluid. Most
likely cause? - ANSWERLymphoma
47 YOW comes in with a BMI of 67 , chafed skin on inner thighs, under breasts, twice
requiring admission for abtx for panniculitis. Also has thick curdy vaginal discharge.Best
long term management for this pt? - ANSWERGastric bypass (NOT panniculectomy!)
37 YOw bruising on arms and abdomen x3w. ibuprofen for HA. afebrile. PE:eccymoses
over upper extremities and trunk. Lungs CTAB, Labs: norm Hb, 6.8k WBC, 45k plt,
Bleeding time is high,PT normal. Bone marrow shows megakayocytes. Explanation for
findings? - ANSWERITP
A 13 YOB has increasingly severe left thigh pain and knee pain and limp for 2 days. He
is 6 ft tall and 145lbs. No Hx of trauma, BMI =20, Passive motion of hip elicits pain, Most
likely Dx? - ANSWERSCFE!
12 hours after rod stabilization of a femoral fracture, 27 YO homeless ,an has sudden
onset of combativeness and disorientation. HR 120, RR 24, BP 140/85. Exam shows
petichiae over axila. Most likely cause? - ANSWERFat embolism
52 YOW has back pain with hx of treatment for breast cancer 5 years ago. Decreases
sensitivity below nipples. Hyperreflexive and decr strength with + babinski in legs, arms
are normal. Where is the lesion? - ANSWERThoracic spinal cord
Previously healthy *YOB has intermittent pain in the right anterior thigh for the past 3
w.activity level is high.mother notes he limps. 25th percentile ht and wt. Vitals normal.
Atalgic gait. Abduction and internal rotation of the feur is limited. Dx? -
ANSWERAvascular necrosis of the femoral head (Legg-Calve-Perthes Dz)
ASX 72 YOW comes in with decreased renal fx. Elevation in Cr over last 3 days. got
2nd renal transplant from 65 YO donor 1 m ago. Most likely explanation for decr renal
fx? - ANSWERAcute rejection - failure to suppress class II antigen recognition in the
host
36 hours after admission for evaluation of diffuse abd pain, a 42 YOw is still obstipated.
She has a 9yr history of scleroderma. Current temp is 100, P 110, RR22, BP 110/60.
Abd is distended with colon dilation and WBC 14k. Next step? - ANSWERShe has signs
of peritonitis - answer is almost always gonna be laparotomy!
, A 68 YOM is broguht to the ED because of recurrent vomiting of bright red blood, and
near syncope x 3 hours. He is afebrile, pulse 110, respirations are 16, BP 90/60 mm Hg
and he has mild epigastric tenderness. Next step? - ANSWERRapid infusion of 0.9%
NS
So fluids first then figure out bleeding
A 67 YOW, 8m bilateral calf pain with walking. initially only after long walk, now only
after 300 ft. pain is relieved with rest. She has hypertension and hypercholesterol. She
is on atherscler drugs and smokes. pulses decr bil.elevated BUN. Next step? -
ANSWERABI is done first before imaging.
Move on to imaging like Duplex if ABI < 0.9
12 hours after pancreatic abscess drainage, a 52 YOM with alcoholism becomes
bradycardic and hypoxic and requires intubation. His FiO2 is 100, with a tidal volume of
1000 and PEEP of 2.5. He still has acidosis with O2 = 48 and CO2 of 40. Next step? -
ANSWERIncrease PEEP
Tidal volume is super high here and should probably be lowered but won't address his
hypoxemia
Only increasing FiO2 or increasing PEEP will increase PACO2
a 60 YOW has a sigmoid resection and colostomy for diverticulitis with rupture. That
night she becomes confused, oliguric and febrile. the area around the colostomy is
indurated and crepitant. Most likely causal organism? - ANSWERClostridium
perfringens!!
Don't get confused by the source!
The crepitus gives it away
A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal
vitals and normal CV and P exams except a low pitched disatolic rumble at the apex
that dissappears when he lies on his R side. Hb is 10. Most liekly dx? - ANSWERAtrial
myxoma!
52 YOW, 2m R foot swelling w/o fever or pain. No trauma history, 25 y histroy of T1 DM.
Pe swelling on dorsal foot and med and lat ankles. The is small effusion over ankle.
Decr sensation below ankles. XR shows osteopenia and disorganized foot. Cause? -
ANSWERLack of normal foot sensation! Charcot foot - a complication of diabetic
neuropathy
62 YOM w hemoptysis for 1w.5 y hx of daily productive cough, 20 y of hypertension, 88
yr pack history. Ca concentration is 11 (high) with coin lesion in lung. Most likely dx? -
ANSWERSquamous cell carcinoma!
& CORRECT SOLUTIONS
A previosuly healthy 47 YOM comes in with 2 weeks of progressive abd swelling. PE
shows distention and shifting dullness, bowel sounds are normal. There is no
tenderness, masses or organomegaly. Paracentesis: 50ml milky chylous fluid. Most
likely cause? - ANSWERLymphoma
47 YOW comes in with a BMI of 67 , chafed skin on inner thighs, under breasts, twice
requiring admission for abtx for panniculitis. Also has thick curdy vaginal discharge.Best
long term management for this pt? - ANSWERGastric bypass (NOT panniculectomy!)
37 YOw bruising on arms and abdomen x3w. ibuprofen for HA. afebrile. PE:eccymoses
over upper extremities and trunk. Lungs CTAB, Labs: norm Hb, 6.8k WBC, 45k plt,
Bleeding time is high,PT normal. Bone marrow shows megakayocytes. Explanation for
findings? - ANSWERITP
A 13 YOB has increasingly severe left thigh pain and knee pain and limp for 2 days. He
is 6 ft tall and 145lbs. No Hx of trauma, BMI =20, Passive motion of hip elicits pain, Most
likely Dx? - ANSWERSCFE!
12 hours after rod stabilization of a femoral fracture, 27 YO homeless ,an has sudden
onset of combativeness and disorientation. HR 120, RR 24, BP 140/85. Exam shows
petichiae over axila. Most likely cause? - ANSWERFat embolism
52 YOW has back pain with hx of treatment for breast cancer 5 years ago. Decreases
sensitivity below nipples. Hyperreflexive and decr strength with + babinski in legs, arms
are normal. Where is the lesion? - ANSWERThoracic spinal cord
Previously healthy *YOB has intermittent pain in the right anterior thigh for the past 3
w.activity level is high.mother notes he limps. 25th percentile ht and wt. Vitals normal.
Atalgic gait. Abduction and internal rotation of the feur is limited. Dx? -
ANSWERAvascular necrosis of the femoral head (Legg-Calve-Perthes Dz)
ASX 72 YOW comes in with decreased renal fx. Elevation in Cr over last 3 days. got
2nd renal transplant from 65 YO donor 1 m ago. Most likely explanation for decr renal
fx? - ANSWERAcute rejection - failure to suppress class II antigen recognition in the
host
36 hours after admission for evaluation of diffuse abd pain, a 42 YOw is still obstipated.
She has a 9yr history of scleroderma. Current temp is 100, P 110, RR22, BP 110/60.
Abd is distended with colon dilation and WBC 14k. Next step? - ANSWERShe has signs
of peritonitis - answer is almost always gonna be laparotomy!
, A 68 YOM is broguht to the ED because of recurrent vomiting of bright red blood, and
near syncope x 3 hours. He is afebrile, pulse 110, respirations are 16, BP 90/60 mm Hg
and he has mild epigastric tenderness. Next step? - ANSWERRapid infusion of 0.9%
NS
So fluids first then figure out bleeding
A 67 YOW, 8m bilateral calf pain with walking. initially only after long walk, now only
after 300 ft. pain is relieved with rest. She has hypertension and hypercholesterol. She
is on atherscler drugs and smokes. pulses decr bil.elevated BUN. Next step? -
ANSWERABI is done first before imaging.
Move on to imaging like Duplex if ABI < 0.9
12 hours after pancreatic abscess drainage, a 52 YOM with alcoholism becomes
bradycardic and hypoxic and requires intubation. His FiO2 is 100, with a tidal volume of
1000 and PEEP of 2.5. He still has acidosis with O2 = 48 and CO2 of 40. Next step? -
ANSWERIncrease PEEP
Tidal volume is super high here and should probably be lowered but won't address his
hypoxemia
Only increasing FiO2 or increasing PEEP will increase PACO2
a 60 YOW has a sigmoid resection and colostomy for diverticulitis with rupture. That
night she becomes confused, oliguric and febrile. the area around the colostomy is
indurated and crepitant. Most likely causal organism? - ANSWERClostridium
perfringens!!
Don't get confused by the source!
The crepitus gives it away
A 45 YOm has daily temps to 100.9 and 15 lb wt loss over 3 m. he has pallor, normal
vitals and normal CV and P exams except a low pitched disatolic rumble at the apex
that dissappears when he lies on his R side. Hb is 10. Most liekly dx? - ANSWERAtrial
myxoma!
52 YOW, 2m R foot swelling w/o fever or pain. No trauma history, 25 y histroy of T1 DM.
Pe swelling on dorsal foot and med and lat ankles. The is small effusion over ankle.
Decr sensation below ankles. XR shows osteopenia and disorganized foot. Cause? -
ANSWERLack of normal foot sensation! Charcot foot - a complication of diabetic
neuropathy
62 YOM w hemoptysis for 1w.5 y hx of daily productive cough, 20 y of hypertension, 88
yr pack history. Ca concentration is 11 (high) with coin lesion in lung. Most likely dx? -
ANSWERSquamous cell carcinoma!
