NBME

Question 1

Lung cancer associated w/ hypercalcemia

Answer 1

Squamous cell carcinoma
2/2 PTHrP release
-don’t confuse this w/ small cell, not the same!!

Question 2

22 yo M w/ GSW to right calf

• normal VS, no exit wound, calf tense and TTP
• passive mov’t of great toe exacerbates calf pain
• normal pulses, cap refill, sensation

Immediate next step?

Answer 2

Surgical decompression
-tense, painful passive ROM = compartment syndrome risk!! needs immediate decompression

-not irrigation of wound or abx…duh need to deal w/ immediate problem

Question 3

30 yo M w/ painless, progressive enlargement of left testicle over 8 mo
-no nodule, scrotum cannot be transilluminated

Dx

Answer 3

Dx = testicular tumor
-almost all testicular masses are malignant

• not hydrocele b/c that would transmit light (able to be transilluminated)
• not epidiymitits b/c fever and severe pain
• not indirect inguinal hernia b/c not painless and not progressive
• not spermatocele b/c that is a palpable lump in the scrotum

Question 4

45 yo M w/ daily 100.9F temps and 15 lb wt loss over past 3 mo

• Hgb 10
• low-pitched, rumbling diastolic murmur heard best at apex that disappears when pt lies on his right

Dx

Answer 4

Dx = atrial myxoma = benign primary cardiac tumor usually (80%) in the LA on the atrial septum

• causes symptosm 2/2 mitral valve obstruction => often mimics mitral stenosis (hence the murmur)
• tumor releases cytokines and growth factors that cause constitutional symptoms (anemia, fever, wt loss)

Question 5

Most common primary cardiac neoplasm

Answer 5

Atrial myxomas- benign tumors, most often in the LA on atrial septum

Question 6

Atrial myxomas

(a) What are they?
(b) Where are they?
(c) Two sets of symptoms

Answer 6

Atrial myxomas

(a) Benign primary cardiac tumors
(b) 80% in the left atrium, other 20% in the right atrium
- on the atrial septum
(c) Cause symptoms by.
i. mitral valve obstruction => mimics mitral stenosis (diastolic rumbling murmur heard at the apex)
ii. growth factor and cytokine release => constitutional symptoms (fever, anemia, wt loss)

Question 7

Define proctocolectomy

(a) Indications

Answer 7

Proctocolectomy = surgical removal of rectum and some (or all) of the colon

(a) Surgical method for ulcerative colitis and FAP ppx

Question 8

60 yo F POD0 from sigmoid resection becomes confused, oliguric, and febrile
-tissues around colostomy are indurated and crepitant

Causative organism?

Answer 8

Clostridium perfinges
-gas gangrene! Surgery compromises blood supply, anaerobic environment is optimal for clostridial growth => necrosis w/in 24-36hrs

Question 9

How to make a diagnosis of gas gangrene

Answer 9

Gas gangrene (2/2 clostridium species s/p bowel surgery): pain at site, signs of systemic toxicity (fever, neuro status change), gas in soft tissue (crepitus in soft tissue)

-crepitus in soft tissue = most sensitive and specific physical exam findings

Question 10

Crepitus in soft tissue

Answer 10

= Gas gangrene 2/2 clostridium species

Question 11

Most common type of hiatal hernia

Answer 11

Hiatal hernia, most common type = sliding hiatal hernia

-much more common that paraesophageal

Question 12

Main clinical feature of VIPoma

Answer 12

Watery diarrhea and the resultant electrolyte abnormalities

Question 13

Urinalysis results expected in pt w/ nephrolithiasis

Answer 13

Kidney stones => microscopic hematuria (30 RBC/hpf in sediment)
hpf = high power field