NBME Surgery

Question 1

Normal liver span

Answer 1

<12cm

Question 2

How much fluid does a burn victim need in the first 24 hours?

Answer 2

To calculate the fluid needed, you must know % of body surface area affected.
Formula: (% body surface) X 4 X kg
50% of fluids in 1st 8 hours
50% in next 16 hrs

Question 3

Prophylaxis for burn wound care.

Answer 3

Infection prevention = topical:

• silver sulfadiazine
• mafenide

Question 4

What is the initial treatment of Acute Pancreatitis?

Answer 4

Vigorous IV Fluids
NPO
Analgesics
Nasogastric decompression if vomiting
Most patients resolve in 3-5 days.

Question 5

Value of K for Hyperkalemia?

Treatment?

Answer 5

Hyperkalemia when K>5.0

Tx = Dialysis

Question 6

What lung neoplasms cause paraneoplastic effects and what are the associated key findings?

Answer 6

Squamous cell carcinoma = PTHrP = hypercalcemia
Small cell carcinoma = SIADH = hyponatremia
Small cell carcinoma = ACTH = more cortisol = Cushing syndrome (hypertension, weight gain, moon facies, abdominal striae, buffalo hump, hyperglycemia)

Question 7

PT and PTT in DIC, HIT, ITP and TTP

Answer 7

DIC = Increased
HIT = normal
ITP = normal
TTP = normal

Question 8

Most important aspect of ventilation of a patient with Acute Respiratory Distress.

Answer 8

High PEEP

Question 9

Next step in management:

After trauma patient is found to have a widened mediastinum.

Answer 9

Next step = spiral CT (CT angio / Aortic angio)

Question 10

Epistaxis with no obvious source of bleeding and continues to bleed after packing. What is the bleeding artery?

Answer 10

Sphenopalatine artery

branch of maxillary artery

Question 11

What do you see on urine analysis of urolithiasis?

Answer 11

Microscopic hematuria

Question 12

Carotid bruit. Next step in management.

Answer 12

Carotid duplex ultrasonography

Question 13

Pancreatic tumor associated with diarrhea.

Answer 13

VIPoma

Question 14

Enterococcus is gram positive or negative?

Answer 14

Gram Positive

Question 15

Pseudomonas is gram positive or negative?

Answer 15

Gram Negative

Question 16

What type of hernia is associated with GERD?

Answer 16

Sliding hiatal hernia

NOT paraesophageal hernia

Question 17

Best test to screen for breast cancer.

Best test to diagnose breast cancer.

Answer 17

Screen with mammogram

Diagnose with core needle biopsy.

Question 18

Complex adnexal cyst. Next step in management.

Answer 18

Laporoscopic exploration

Question 19

Mechanism of indomethacin

Answer 19

Cyclooxygenase inhibition

Question 20

Midsystolic click. Dx?

Answer 20

Dx = Mitral valve prolapse

Associated with Marfans and Elher-Danlos

Question 21

What are the antibodies to in Hashimoto vs Graves?

Answer 21

Hashimoto = anti-thyroid peroxidase (antimicrosomal) and anti-thyroid globulin
Graves = anti-thryoid stimulatin immunoglobulin

Question 22

What is toxic synovitis?

Answer 22

Synovial inflammation up to 4 weeks after URI or GI viral illness.

Question 23

Hepatic mass with central scar on imaging. Dx? Next step?

Answer 23

Focal nodular hyperplasia. Treatment is not necessary.

Question 24

Large bowel obstruction, but there is no mechanical obstruction. Dx? Tx?

Answer 24

Dx = Ogilvie syndrome
Tx = Gentle enema or nasogastric suction
if these fail then Sigmoid-guided placement of a rectal tube

Question 25

What causes hypocalcemia in an alcoholic

Answer 25

The hypomagnesemia in an alcoholic causes decreased PTH and thus decreased calcium

Question 26

Therapy for patient with pneumonia that has no spleen.

Answer 26

Ceftriaxon and vancomycin

Question 27

Pregnant woman with tingling of index and middle fingers. Dx? Test to confirm diagnosis?

Answer 27

Dx = Carpal tunnel syndrome | Test to confirm diagnosis = nerve conduction study (electromyography)

Question 28

Hidradenitis suppurativa. What glands are involved?

Answer 28

Apocrine glands

Question 29

Most appropriate to predict patient's risk for perioperative myocardial infarction before repair of AAA.

Answer 29

Radionucleotide scan with thallium and dipyridamole

Question 30

How to evaluate adequate fluid resuscitation in a patient.

Answer 30

Urine output must be more than 30 mL/hr.

Question 31

Adnexal mass -- next step

Answer 31

Transvaginal Ultrasound

Question 32

Drug used to keep Ductus Arteriosus open in Tetralogy of Fallot. vs Drug used to close Ductus Arteriosus

Answer 32

``` Open = Prostaglandin E1 Close = Indomethacin (NSAID) ```

Question 33

Mechanism and side effect Ketorolac

Answer 33

Mechanism = Ketorolac is an NSAID, which inhibits synthesis of prostacyclin. Side effect = 1) Renal ischemia. (prostaglandins vasodilate the afferent areteriole, so NSAID will cause arteriolar constriction) 2) Gastric ulcers (prostaglandins protect gastric mucose, so NSAID will cause removal of protective layer)

Question 34

Heart sound: Opening snap

Answer 34

Mitral stenosis

Question 35

Treatment for zero urine output

Answer 35

Place a foley or unkink the catheter

Question 36

Low urine output after surgery = (how much?) | Treatment

Answer 36

< 0.5 mL/kg/hr Tx = 500 mL 0.9% saline challenge If improves = dehydration If does NOT improve = Intrinsic renal damage

Question 37

How to diagnose Sarcoidosis.

Answer 37

Sarcoidosis is a disease of noncaseating granulomas present in many organs. Most often involving the lungs. Discover on X-ray: Bilateral mediastinal and hilar lymph nodes with diffuse interstitial disease bilaterally.

Question 38

Minimum FEV1 to remain in patient to consider for pneumonectomy surgery

Answer 38

800 mL

Question 39

"string sign" on barrium swallow

Answer 39

Crohn disease

Question 40

How to diagnose physiologic jaundice?

Answer 40

High unconjugated billirubin

Question 41

What to worry about in anesthesia of patients that are on chronic prednisone. How to treat?

Answer 41

Sudden hypotension, due to adrenal insufficiency. | Tx = hydrocortisone

Question 42

Treatment of intussusseption. | Treatment of meconium ileus

Answer 42

Tx for intussusseption = Contrast enema | Tx for meconium ileus = Gastrografin enema

Question 43

Diagnosis for Meckel diverticulum

Answer 43

Technetium scan

Question 44

Subcutaneous emphysema in the upper chest and lower neck. Dx?

Answer 44

Traumatic rupture of trachea or lower bronchus.

Question 45

How to control the symptoms of chronic pancreatitis?

Answer 45

Control steatorrhea = pancreatic enzymes | Hyperglycemia (diabetes) = Insulin

Question 46

Major symptoms of pt with antithrombin III deficiency.

Answer 46

Increased thrombosis

Question 47

Definitive diagnostic study for esophageal rupture.

Answer 47

Contrast esophogram

Question 48

Treatment for esophageal rupture

Answer 48

IV fluids NPO Antibiotics H2 blockers

Question 49

Common cause of retinal artery occlusion

Answer 49

Carotid thrombosis | much check for carotid stenosis

Question 50

Erythema and fullness between the gluteal folds. Fever. Diagnosis?

Answer 50

Pilonidal abscess

Question 51

What other diagnsosis should you look out for if you find flail chest? Next steps in management?

Answer 51

Look out for pulmonary contusion. Pulmonary contusion is sensitive to fluid overload, so restrict fluids and use diuretics. Also look out for transection of aorta.

Question 52

Cause of fever during surgery or immediately after surgery

Answer 52

Wonder drugs = malignant hyperthermia = during surgery | Immediately after surgery = bacteremia

Question 53

Causes of post op fever depending on POD (post-op-day). Next step.

Answer 53

POD 1 = Wind = Atelectasis = incenstive spirometry POD 2 = Wind = Pneumonia = broad spectrum antibiotics POD 3 = Water = UTI = take foley out POD 5 = Walking = DVT/PE = Heparin bridge Warfarin POD 7 = Wound = Cellulitis POD 10-14 = Wound = Abcess = ultrasound/CT = antibiotics and incision drainage