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Q1) You have been asked to perform a preoperative consultation on a 65yearold male who will be undergoing
a testicular hernia repair. Of the following findings, which is of most concern in predicting a cardiac
complication in this patient undergoing noncardiac surgery?
a) Age over 60
b) History of myocardial infarction 3.5 years ago
c) Harsh systolic crescendodecrescendo murmur radiating to the carotids
d) ECG and subsequent telemetry showing up to five PVCs per minute
e) Serum creatinine 2.0 mg/dL
Q2) A right hemicolectomy is performed on a 57yearold woman with adenocarcinoma who had a preoperative
elevation of carcinoembryonic antigen (CEA) to 144. After falling to normal levels postoperatively, her most
recent (24month) followup level was 86. Correct statements regarding CEA and colorectal tumors include
which of the following?
a) elevated CEA is indicative of a tumor of gastrointestinal origin
b) a low CEA level after resection of a colon tumor is a poor marker of disease control
c) 90% of colorectal tumors produce CEA
d) there is a high likelihood of liver involvement if the CEA level is high (greater than 100 ng/mL)
e) CEA levels are unusually low in cigarette smokers

Q3) A 63yearold man is seen 3days postop and shows signs of fever, abdominal pain, nausea, and anorexia.
His urine output is 100 ml over the last 24 hrs. His blood pressure is 84/62, and his pulse is 138. His response to
this physiologic state includes which of the following?
a) Increase in sodium and water excretion
b) Increase in renal perfusion
c) Decrease in cortisol levels
d) Hyperkalemia
e) Hypoglycemia

A1) c harsh systolic crescendodecrescendo murmur radiating to the carotids

A2) d here is a high likelihood of liver involvement if the CEA level is high (greater than 100 ng/mL)
A3) d hyperkalemia
Must have book on your surgery rotation:Surgical Recall
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SHELF / USMLE Step 2 Practice Questions > Surgery (set #2)

SHELF / USMLE Step 2 Practice Questions> Surgery
Q1) A workup for a patient with frequent and multiple areas of cutaneous ecchymosis discloses a large spleen
and evidence of immune (idiopathic) thrombocytopenic purpura (ITP). ITP includes which of the following?
a) A significant enlargement of the spleen
b) A high reticulocyte count
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c) Megakaryocytic elements in the bone marrow

d) An increase in platelet count on cortisone therapy
e) Patient age of less than 5 years

Q2) 4. A 27yearold man undergoes general anesthesia for a hernia repair. As the anesthesia begins, his jaw
muscles tense and he becomes generally rigid. He becomes febrile, tachycardic, and tachypnic. Intravenous
administration of which of the following agents may be lifesaving?
a) Suxamethonium
b) Nitrous oxide
c) Succinylcholine
d) Dantrolene
e) Phenobarbital

Q3) An 80yearold man is admitted to the hospital complaining of nausea, abdominal pain, distention, and
diarrhea. A cautiously performed transanal contrast study reveals an apple core configuration in the
rectosigmoid area. Which of the following is the most appropriate management at this time?
a) Colonoscopic decompression and rectal tube placement
b) Saline enemas and digital disimpaction of fecal matter from the rectum
c)Colon resection and proximal colostomy
d)Oral administration of metronidazole and checking a Clostridium difficile titer
e)Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric
ischemia

A1) d An increase in platelet count on cortisone therapy (Corticosteroid therapy increases the platelet count
in over 75% of cases and provides the best indication that splenectomy will be of lasting benefit.)
A2) d this is a case of malignant hyperthermia, pts may become severely acidotic and develop rhabdomyolysis.
Pathology shows diffuse segmental muscle necrosis. Tx is dantrolene, which prevents release of calcium from
the SR, and supportive measures.
A3) c Colon resection and proximal colostomy. An apple core lesion in the distal colon is diagnostic of colon
cancer
Must have book on your surgery rotation:Surgical Recall
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SHELF / USMLE Step 2 Practice Questions > Surgery (set #3)

SHELF / USMLE Step 2 Practice Questions> Surgery
Q1) A 75yearold male undergoes an abdominal CT looking for liver metastases from a known colonic adenoma.
On the CT a 4.9 cm abdominal aortic aneurysm(AAA). Which of the following risk factors is NOT a contributor to
this pt's AAA?
a) His age.
b) Hypercholesterolemia.
c) Diabetes.
d) Smoking.
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e) Hypertension.
Q2) A 64 year old diabetic male with a history of PVD presents to vascular clinic with pain and paresthesias of
the L foot. The pain improves with rest but always returns after walking approximately 6 city blocks. Which of
the following likely represent this patients test results after and ABI?
a) ABI = 1.1 1.4
b) ABI = 0.9 1.0
c) ABI = 0.6 0.8
d) ABI = 0.4 0.5
e) ABI < 0.3

Q3)A 7yearold girl fell while sledding and suffered a jagged wound to her right eyebrow and forehead. After
local anesthesia and thorough cleaning, you plan for primary closure. Which of the following statements is true
concerning facial wound repair?

a) Permanent suture material is preferred

c) Sutures should be removed in 2 weeks to minimize infection
d) Sutures should be placed 3 to 4 mm apart and 4 mm from the wound edge
e) Knots should be centered on the wound

A1) c diabetes. The Aneurysm Detection and Management Veterans Affairs Cooperative Study Group trial
(commonly referred to as the ADAM trial) found the following factors to be associated with increased risk for an
AAA: advanced age, greater height, coronary artery disease, atherosclerosis, high cholesterol levels,
hypertension, and smoking. The risk is lower in women, African Americans, and diabetic patients.
A2) c ABI = 0.6 0.8. An ABI < 0.95 indicates significant narrowing of one or more blood vessels in the legs
ABI < 0.8 indicates pain in the foot, leg, or buttock may occur during exercise (intermittent claudication).
ABI < 0.4, symptoms may occur when at rest.
ABI < 0.3 indicates severe limbthreatening PAD is probably present
A3) a Permanent suture material is generally preferred for the face. Needle marks can be prevented by
removing sutures earlier rather than later. The knot should be brought to one side of the wound, and tension
should be adjusted so that the skin edges are opposed without compromising the blood supply. On the face,
sutures should be ~34 mm apart and be placed 2 mm from the wound edge.
Must have book on your surgery rotation:Surgical Recall
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SHELF / USMLE Step 2 Practice Questions > Surgery (set #4)

SHELF / USMLE Step 2 Practice Questions> Surgery
Q1) A 15yearold male cut his arm while climbing a chain link fence. No foreign bodies are found in the cut anf
the wound is thoroughly cleaned. The patient was never immunized against tetanus toxoid. Which of the
following represents appropriate management?
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a) The patient may be given a toxoid booster.

b) The patient may be immunized in three separate doses.
c) The patient may be treated with penicillin as prophylaxis againstClostridia tetani.
d) Passive immunization with tetanus immunoglobulin is recommended.
e) The wound should not be sutured.
Q2) A 64 year patient who has been on IV heparin for 3 days for a DVT begins to have hematemesis from a
bleeding GI ulcer. What is the appropriate management?
a) Decrease the heparin dose & administer blood products as needed.
b) Switch to Coumadin.
c) Stop heparin and observe for 3 day to see if the DVT resolves.
d) Stop the systemic heparin and administer thrombolytics directly to the femoral vein.
e) Stop the systemic heparin and place an IVC filter.

Q3) A 43 y/o male presents to the ED with abdominal pain and 3 days of emesis. On 1st assessment he has a
temp of 103.2, a bp of 72/40 and a rigid abdomen. Which of the following diagnostic studies would most likely
reveal the diagnosis?
a) a CBC with diff.
b) an abdominal flat plate
c) ESR
d) an obstruction series
e) an upper GI

A1) b The patient may be immunized in three separate doses as long as the wound is clean.
A2) e Stop the systemic heparin and place an IVC filter. PE must be prevented, however anticoagulants cannot
be given in the setting of a bleed.
A3) d an obstruction series will demonstrate free air (peritonitis, perforated viscus) on the CXR.
Must have book on your surgery rotation:Surgical Recall
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Foolproof Templates for Surgery Notes

Here are templates for preop, postop, and progress notes that will ensure you don't forget anything important
when rounding on your surgical patients
Surgery PreOp Note
Surgery PostOp Note
Surgery Progress Note
I am currently studying for my surgery Shelf Exam and have come across 2 great books, both are cased based and
work through clinical scenarios much like the actual exam:
Surgical Attending Rounds : presents each topic as a realistic clinical case with questionandanswer teaching
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points and clinical decisionmaking algorithms

NMS Surgery Casebook: surgical cases that begin with a clinical scenario and go through the decisionmaking
process of patient management stepbystep.
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MedSpot on MedSource: Coagulopathies

MedSpot 6.21.07 Coagulopathies
The values of the PT & PTT provide a fair amount of information when trying to narrow down the etiology of a
bleeding disorder. The following information is incredibly testable (boards, shelf, etc) and useful on the wards

PT

PTT

nl.

factorVIIdeficiency

warfarin
vit.Kdeficiency
liverdz.
inhibitoroffactorVII

nl

hemophilias
vWD

heparin
factorinhibitors
antiphospholipidAb

prothrombindeficiency
fibrinogendeficiency
factorVorXdeficiency
combinedfactordeficiency

heparin+warfarin
DIC
liverdz
inhibitorofprothrombin

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InheritedCoagulopathies

AcquiredCoagulopathies

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Labels:hematology,internal medicine,USMLE step 2

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SHELF / USMLE Step 2 Practice Questions Heme / Onc

SHELF / USMLE Step 2 Practice Questions> Internal Medicine > Hematology / Oncology
Q1) A 72yearold for a routine exam. She has hypertension for which she takes a daily aspirin and ramipril. Her
medical history is otherwise noncontributory.
On physical examination, pulse rate is 80/min, and blood pressure is 140/80 mm Hg. There is no bony
tenderness, splenomegaly, or lymphadenopathy. Laboratory studies indicate a hemoglobin of 13.6 g/dL ,
leukocyte count of 7200/L, and a platelet count of 247,000/L. Total serum protein level is elevated to 8.0
g/dL, and serum creatinine and calcium concentrations are normal. Serum protein electrophoresis reveals a 1.2
g/dL monoclonal protein spike, further identified as IgG by immunofixation. Bone marrow aspirate smear
shows 7% plasmacytosis. No lytic lesions are detected on bone survey. hich of the following is the most
appropriate next step in the management of this patient?
a)
b)
b)
d)

Thalidomide and dexamethasone

positron emission tomography
bisphosphonates
repeated serum protein electrophoresis in 3 to 6 months

Q2) A previously healthy 45yearold man presents for the 4th time in 6 months with URI symptoms complaining
of a sorethroat and waxing and waining cervical lymhadenopathy? He has undergone several courses of
antibiotics, but his symptoms never fully disappear. On exam he has a low grade fever and a bp of 105/70. A
left cervical nontender, nonmobile lymph node measuring 3x3cm is appreciated. No other lymphadenopathy is
palpable. A lymph node biopsy is performed. Which of the following is the most likely diagnosis?
a) Burkitt lymphoma
b) diffuse large cell lymphoma
c) follicular mixed lymphoma
d) follicular small cleaved cell lymphoma
e) immunoblastic lymphoma

Q3) A 50yearold man complains of recent onset of generalized pruritus. He has previously been in excellent
health, eats a normal diet, has never smoked, and does not take any medications. On physical examination, he
has ruddy facies and a palpable spleen tip. Results of fecal occult blood testing are negative. The oxygen
saturation at rest is 99% on room air. Laboratory studies are notable for a hematocrit of 61.0% compared with a
value of 44.5% documented 5 years ago, leukocyte count of 12,300/L, mcv of 79 fL, and platelet count of
550,000/L. Serum chemistries are normal except for a reduced serum iron saturation and serum ferritin
concentration. Results of upper and lower endoscopy are normal. Which of the following is the most appropriate
management of this patient?
a) Phlebotomy and anagrelide
b) oral iron supplementation and lowdose aspirin
c) hydroxyurea and aspirin, 325 mg/d
d) phlebotomy and lowdose aspirin

A1) d repeated serum protein electrophoresis in 3 to 6 months (Monoclonal gammopathy of unknown

significance (MGUS) is characterized by the presence of serum monoclonal gammaglobulin without the clinical
features of multiple myeloma)
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A2) d follicular small cleaved cell lymphoma

A3) d phlebotomy and lowdose aspirin (polycythemia vera elevated red blood cell mass, a normal blood
oxygen saturation, and the presence of splenomegaly)
Must have book on your medicine rotation:Pocket Medicine 2nd Ed.
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SHELF / USMLE Step 2 Practice Questions Rheumatology

SHELF / USMLE Step 2 Practice Questions> Internal Medicine > Rheumatology
Q1) A 36yearold man is evaluated for worsening left knee pain and swelling of 2 days' duration. He does not
have dysuria or any systemic symptoms. He has not seen a physician since his last routine physical examination,
which was normal and occurred 2 years ago. His father has gout and coronary artery disease. On physical
examination, he is afebrile. He walks with a limp because of his pain. The left knee is warm, tender, and
distended. The remainder of the examination is unremarkable.
Laboratory Studies
Hemoglobin 13.3 g/dL
Leukocyte count 8600/L normal differential)
Platelet count 320,000/L
Urinalysis Normal
Aspiration of the knee joint yields 20 mL of fluid (leukocyte count, 30,000/L; 94% neutrophils). No crystals are
seen on polarized light microscopy of the fluid, and Gram stain is negative. Results of mucosal, blood, and
synovial fluid cultures are pending. Which of the following is the most appropriate next step in this patient's
management?
a) IV antibiotics; repeat aspiration of the knee joint
b) NSAIDS
c) NSAIDS and oral antibiotics
d) Knee radiograph; erythrocyte sedimentation rate
Q2) A 45yearold woman is evaluated for a facial rash of 6 months' duration that involves the cheeks and nose.
She is unsure whether sun exposure worsens the rash. She does not have rash elsewhere, fatigue, ulcers, or
joint pain. She has a history of autoimmune hypothyroidism with positive antimicrosomal antibodies and is
antinuclear antibody positive. Physical examination reveals an erythematous rash with discrete papules and
pustules limited to the cheeks, nasolabial folds, and nose. The remainder of the examination is unremarkable.
Current laboratory studies, including complete blood count, serum chemistry studies, and thyroidstimulating
hormone, are normal. Which of the following is the most likely diagnosis?
a) dermatomyositis
b) systemic lupus erythematosus
c) roseacea
d) seborrheic dermatitis
e) psoriasis

Q3) A 60 yearold woman with rheumatoid arthritis is hospitalized for a 3day history of fever, rigors, and cough
productive of rusty sputum. Outpatient medications include alendronate, hydroxychloroquine, etanercept, a
multivitamin, and calcium supplementation. On physical examination, T = 38.1 C (100.6 F), HR = 90/min, RR
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= 20/min, and bp = 130/72 mmHg. Pulmonary examination reveals crackles in the right lung base.
Cardiovascular and abdominal examinations are unremarkable, and musculoskeletal examination reveals no
joint swelling or tenderness. Laboratory studies, sputum Gram stain, and blood and sputum culture are
performed. Chest radiograph reveals right lowerlobe pneumonia, and intravenous antibiotic therapy is
initiated. Which of the following is the most appropriate adjunctive step in this patient's management?
a) discontinue alendronate
b) discontinue etanercept
c) discontinue hydroxychloroquine
d) administer stressdose hydrocortisone therapy

A1) a IV antibiotics; repeat aspiration of the knee joint Drainage and IV antibiotics are standard treatment
for a closedspace joint infection.
A2) c roseacea An inflammatory dermatitis characterized by erythema, telangiectasias, papules, pustules,
and sebaceous hyperplasia that affects the central face, including the nasolabial folds.
A3) b discontinue etanercept Antitumor necrosis factor therapy is contraindicated in patients with
infection.

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