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How to use this summary: you should review the scenarios in the context of what you’ve learned with Odyssey, particularly with regard to how you organize and deliver information, and how you prioritize what you wish to discuss. Make sure that you view each scenario critically, since I do not want to suggest that all the scenarios have acceptable responses. Some candidates use socially restricted language. I am not suggesting that I condone their choices of language, but by the same token I wish to preserve their emotion, which is an integral part of their experience. I therefore have done minimal editing of phrasing (and of spelling, too.) More detailed summaries yield far greater information than those which simply state the topic. I am grateful for this candidate’s thoughtfulness and generosity in sharing his or her exam experience which can benefit so many others. Odysseus Argy, MD
March 2004 FIRST ROOM Junior Examiner: 44 year old female in ER with nausea, vomiting, abdominal pain and distension for 72 hours – what would you like to do? Response: Started with regular stuff, a few directed questions, most interested in residual bowel function (minimal stool, flatus-intentionally vague) and prior operative history (none). Then went to exam, no fever or tachy, diffusely tender and no peritoneal findings – negative rectal. Then went to labs and studies – labs normal except for WBC of 13,000 and plain films showed distal SBO with maybe some gas and stool in colon (again, intentionally vague). So, I summarized work up so far, likely had SBO of unknown etiology that would require exploration with negative prior surgical history BUT that I wanted to start with NGT, IVF and contrast enema from below to R/O colonic obstruction. Then admitted – she improved somewhat so went ahead with an Abd CT scan. This confirmed distal SBO and o/w negative. She worsened overnight – asked about 4 classic indications for emergent exploration (tachy, fever, peritoneal findings, leukocytosis) – and went to OR. Large, socked in mass involving the distal ileum – he wanted differential: Likely carcinoid given mesenteric reaction and location, also mentioned adenocarcinoma, TB, crohns, etc. Then looked around, few very small lesions on liver – I explained that this was consistent with carcinoid or adenocarcinoma and that the primary lesion needed to be removed en-bloc if possible given the obstruction (I didn’t mention bypass and he didn’t ask) so did ileocolectomy with primary anastamosis and sent for frozen, mentioned that whatever primary was, likely wasn’t curable and was about to say that if it was carcinoid, I would debulk or wedge out liver mets if possible as debulking can make big difference in symptom control and outcome BUT he cut me off and that was the end of question.
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Superior Oral Board Results – 90+% pass rates
Toll free 877 BE READY
he said then lets not do it and asked what do you want to do? Went to OR. found only 3 normal glands and closed her up.com Odyssey Health Communications. I explored her neck. he asked – I really didn’t want to re-explore her neck so I said lets send intact PTH. I also mentioned sternotomy.OdysseyHealth. So from there I went to ERCP. identified the other 3 glands. described 50% decrease from preop level 5 minutes after removal. Came back as adeno Ca at ampulla. sent to path and confirmed adenoma. concerning for malignancy and went to ABD CT. Next. stones). explore abdomen. likely she had a missed adenoma but unrecognized hyperplasia possible and also mentioned may not even be primary hyperparathyroid. Inc. Mentioned MRI – he asked if this would help. None seen. Showed ductal dilatation – I asked about pancreatic mass – he smiled and said not really. Response: He clearly didn’t want to waste a lot of time on history or physical. I prepared for OR and explored the patient. malignancy.OdysseyHealth. Kocher – he stopped me here. He asked me to describe what I would do. I said it might but probably not. Went with RUQ US to r/o gallstones and confirm biliary ductal dilatation. end of case. mediastinotomy. started with transcervical thymectomy and then did bimanual palpation – found nodule. I think he was a little irritated with all the preop fooling around but I felt critical to establish correct diagnosis and I was a little thrown by the way he described the Nuc med study. He asked “what are you going to talk to the GI guy about first” I said I’ll want brushings. Phos. Even did pelvic and rectal to help r/o obturator. localized with Sestamibi – mild increase in mediastinum (intentionally mild finding) then did CT – negative. look for metastatic disease. I then gave a small dissertation on primary hyperthyroidism. I really emphasized r/o hernia on exam in ER work-up and forgot to mention above. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY .com www. he looked very unimpressed and asked if I had that capability at my current hospital. Vertical midline. PTH and 24 urinary calcium. Also could have sampled liver mets prior to resection and that probably would have been more typical. etc. I said no and he said then you don’t have it here. I think they liked a more methodical work-up with relatively benign exam. although stones still possible. This was much more of a what are you going to do question. opened old incision but prepped out her chest.EXAM 4 March 2004 p2 Commentary: I’m sure I passed this question – could have opted to explore right away based on negative prior operative history. No stones. I said. dilated intrahepatic and extrahepatic biliary tree to level of the ampulla. What else could it be he asked – mentioned BFHH. Then I re-established diagnosis with serum Ca. etc as other options if the thymus had been negative – also asked for old op reports prior to OR Junior Examiner: 55-year-old male sent to you with abdominal pain and jaundice. asked about family history of endocrinopathies (negative) and her exam was negative. mobilized R colon. biopsy if lesion seen and pro/con stent. Commentary: Sure I passed this question as well. Senior Examiner: Female in her 70’s referred to your clinic after another surgeon unsuccessfully explored for primary hyperparathyroidism. What next. www. What do you want to do? Response: Started with questions regarding symptoms (she had bone pain.
sclerosed or started on any meds. risk of re-bleed. I could have discussed less radical surgical options for ampullary malignancy – just mentioned as thing NOT to do. SECOND ROOM Senior Examiner: Internist sends you a 56-year-old women with a mid rectal cancer that was diagnosed in the midst of hospitalization for an anterolateral MI one month ago. etc. So. which would have been very reasonable and certainly would have done if ERCP were negative. Commentary: Felt like I really nailed this question. not available. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . IV’s. etc. Staged with CT and EUS – mid rectal lesion. started her on B blockade and did a liver biopsy which she had not yet had done. He makes the point of mentioning that she’s had essentially no work up for her MI. Type and Cross. circumferential. octreotide gtt. First. Then wanted to refer her to a cardiologist for work up (thinking she really ought to be cathed at some point) ended up getting an echo to check ventricular function and then started talking about her rectal cancer work up.EXAM 4 March 2004 p3 Commentary: Clearly passed this question – I could have mentioned a couple of other things in the work up. Scope and sclerose or band. CEA level was normal and no evidence metastatic disease. What would you like to do? Response: I asked if she had been banded. admit to SICU and ready for EGD. Second. preferably 6 months) and need for neoadjuvant therapy. If I’d done EUS he might have given me in situ disease but the path specimen had 2 positive nodes so I know I did the right thing with the Whipple. I said I would already have interventional radio on their way in to place a TIPS – of course.OdysseyHealth. Off she went and returns to ER a year later with an acute upper gi bleed: NGT. So.com www. I discussed indications for transrectal excision but was very clear that she was NOT a candidate for this given extent of disease and thickness of lesion. call for O neg. Make sure you can take this question from initial management to rare patient requiring surgical management. meds. Inc. I intubated and went to Sengsten Blakemore tube under flouro – this slowed the bleeding down but did not stop it. Response: I started off by mentioning that she’ll need a full work-up for her rectal cancer but. Senior Examiner: 42-year-old female referred to your office from a GI colleague after a single episode of esophageal variceal bleeding. I asked some directed questions about cardiac symptoms. she’ll also need a full work-up for her MI.explained best option for her given no ascites and no encephalopathy and potential need for future transplant.OdysseyHealth. He said “no. I summarized that I felt I’d done everything I could to conservatively manage her bleed and so off to the OR we go (glad I had already established her as a Childs Class A) – went with distal splenorenal shunt. Started neoadjuvant and she obstructs 2 www. assuming she is an operative candidate. She stops bleeding but starts back up the next day and now unstable. I did not do EUS. He wouldn’t let me scope (gi unavailable) and now really bleeding. that’s why she’s here to see you” I started with a two or three sentence dissertation on variceal bleeding. Then I established her as a Childs class A. I then mentioned desire to get her out as far as possible from her MI (minimum of 3 months.com Odyssey Health Communications.
Never mind that 700cc is not enough to put a teenage kid into 3rd class shock. I gave him some more fluid and off to the OR. Plus. Comments: I was really upset about this question because I felt he had DELIBERATELY kept me from detecting the effusion – he knew that I was suspicious about it. He kept interrupting me and wouldn’t let me just spit it out. I admitted her again. 200cc out of chest tube in one hour while in the OR – tried to push me to thoracotomy but I said no. The entire scenario was designed to get me to go to the OR for the wrong reason. Pelvis films and exam had ruled out bleeding in chest. preop Swan. So. particularly after the NGT was in the abdomen. 20cc per kg bolus. I felt it was basically a very straightforward problem – she needed her cardiac disease worked up and I really thought he would just let me send her off to cardiology for work up and the critical points were that she needed to have resection put off for 6 months if able and then needed a full work-up for her rectal cancer which I did. Comments: This was an irritating question for me. Called for trauma films and asked about CXR and Pelvis and explained probable bleeding and importance of these films in that setting. call for O neg blood. I also had the feeling that if I www. He asked “when would you give patient blood” – I said if he kept bleeding or stayed unstable. I’m sure I passed the question – I should have been more clear about ruling out residual reversible ischemia right at the beginning of the work up. So. Asked anesthesia how patient was doing – hypotensive – asked them to auscultate chest. So. he clearly wanted me past listening to the kid’s chest during primary survey because he knew that if I heard decreased BS I would have stopped to place a chest tube. “ok – I’m concerned about diaphragmatic rupture with splenic laceration – let place an NGT and try to confirm.OdysseyHealth. pelvis and he had abdominal pain. etc. I could have done a DPL or fast exam in ER but I felt that CXR. I said. deliver it up and divert with end colostomy and mucous fistula. Goes below diaphragm so I ask – any effusion on the repeat film. scrubbed out to place left chest tube. Mobilize the sigmoid colon. Does ok for a little bit but then becomes completely obstructed. I explored him through a midline abdominal incision – small splenic lac and diaphragm is ok. maximize fluid status and B blockade and then plan diversion with hope for definitive resection later. I re-assessed vital signs – unstable. No BS left side. Response to fluids? He improves somewhat. trauma labs. 700cc blood back and his pressure improved. send T&C. they’re ok” what do you want to do? Response: 2 large bore IV’s. He tells me “you’ve gone through the ABC’s. www. Scrubbed back in. I admit her and have GI place a stent. I place NGT and repeat film. He ended the case here. Comes into ER with left sided upper abdominal pain and hemodynamically unstable. repaired spleen and closed abdomen. He wanted to bog me down in the details of this or that and I had to fight to get my key points in. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . He asked about anesthesia and I said I’d go with a transverse left lower quadrant incision using a spinal. back to SICU for fluid resuscitation.OdysseyHealth.com Junior Examiner: 14-year-old boy falls (? off bike) and lands on left side. other than the pressure.com Odyssey Health Communications. Inc. His response was just that haziness. He tells me pelvis is normal and CXR ok except left diaphragm a little hazy.EXAM 4 March 2004 p4 weeks into her therapy.
Rest of exam c/w cholangitis so placed IV’s. Response: So. Main issues were recognizing the patient’s sepsis and placing appropriate lines. use of SPA and wanted to get to repair of the hernia but he never let me get there.EXAM 4 March 2004 p5 had placed a chest tube in the ER he would have made it a diaphragmatic hernia and stool would have been coming out of the kids chest. he kept bogging me down in management of ascites. We talked about this ad nauseum and then I mentioned need for diagnostic and therapeutic tap. then asked for ERCP (also unavailable).com www. Inc.OdysseyHealth. Preload was good with real low SVR so started some dopamine and asked for PTC (unavailable). dose of diuretics. fever and jaundice. she’s sick and already has a cholecystostomy tube in. checked some labs. though. Talked about serum to ascites albumin gradient. patient went into hepatorenal syndrome. do a tap just prior to repair and then go to the or for hernia repair. he directed us into complications of management. etc. Instead. Went to the ICU to resuscitate and went with bedside US to document ductal dilatation and check for stones. choledochotomy. No stones. Emphasized vitals on exam – temp. I lined her up to make sure her hemodynamics were consistent with sepsis. h/o gallstones. Senior Examiner: First comments on what a rough time I had with that last question and then presents a middle aged man sent to your clinic with abdominal ascites and an umbilical hernia with atrophic changes in the skin over the defect. get medical control of their ascites. Do you want to remove the gallbladder right now? No. They may have been a little surprised that I placed a percutaneous www. I had to readmit him. Junior Examiner: Elderly female in ER with abdominal pain. started AB’s and mentioned my plan to get her tanked up and then urgently decompressed. Not sure if I passed this question or not. At that point. I felt this examiner knew that I clearly knew how to manage this clinical problem and almost wanted to prevent me from saying it. etc. I asked about any prior work-up or meds for his ascites (none) and then asked about known etiology of his ascites (known alcoholic and liver cirrhosis on CT) Brief H&P and then made a few summary statements about need for urgent repair of hernia before it ruptures and admitted the patient for bed rest and maximal medical therapy of his ascites. Kocher incision. Asked a few directed questions about prior biliary surgery. End of question Commentary: Real straight forward question. Remember that most patients with ascending cholangitis improve with fluids and AB’s and are able to be decompressed urgently rather than emergently. dilated ducts and disdended gallbladder – because we were there I asked for US guided percutaneous cholecystostomy with hopes of decompressing her that way. irrigated out the duct and placed a T-Tube. I stated she needed emergent ductal decompression so off to the OR. etc. What would you like to do? Response: Started by stating my concern that she might have ascending cholangitis with Charcot’s triad. At this point. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . Comments: Once again.OdysseyHealth. End of case. Instead. She only mildly improved and then worsened with deteriorating hemodynamics. Make sure to line patients up and be aggressive with ICU cares. You admit these patients.com Odyssey Health Communications. pressure and pulse were all consistent with early sepsis. Sure that I passed the question.
Said I would resect it. even though he wanted to move on. potential use of preop ureteral stents. diverticulitis. went to the OR. He was incredulous and asked if I could do anything else. He then ended the question. THIRD ROOM Junior Examiner: Elderly female in ER with LLQ pain. So. Described localization of ureter.OdysseyHealth. he ended the question before I could describe management of the injury. sent off some blood cultures and obtained a CT scan. He had a photo and handed it to me (actually pretty decent quality image) and I saw air and fluid around what looked like the proximal anastamosis. Commentary: Feel I passed this question but I sort of lost focus here.com Odyssey Health Communications. Off to OR. AB’s. Also. Senior Examiner: 66 year old male with prior aortic bi-iliac graft presents with abdominal pain and fever. He seemed surprised – she did have diffuse ischemic changes in the mucosa. the ureteral injury was strange because he never asked for any technical details about the resection and then. I admitted her. Inc. I said I was very concerned patient might have an infected graft and admitted for IV AB’s.EXAM 4 March 2004 p6 cholecystostomy in patient without acute cholecystitis but I though it was worth a shot given how sick she was. ulcerative colitis. place the Axbifem first and then come back later to excise the graft. bring up end stoma and leave a Hartmann’s pouch. No evidence obstruction.com www. Asked a few directed questions about any past history or problems (none) and exam showed no peritoneal findings. I stopped him and stated that I would have obtained a CT scan the night of her admission. I then checked some labs and films. What do you want to do? Response: I received some very strong signals that this examiner was not interested in any belaboring questions so I after fumbling for a few moments. How would you manage her? Response: Mentioned the things I’d be worried about in a patient like this: ischemic colitis. No evidence full thickness necrosis.OdysseyHealth. Said I could do a staged procedure. then went with flex sig to r/o ischemic colitis. dead sigmoid colon. He threw me off at the beginning of the scenario by saying the ER had already drawn some labs and it made me assume that he didn’t want to mess around with that stuff but then later on I didn’t have some info that I wanted. after I described steps to avoid injury. Then he said I looked down and saw clear fluid rising up near the iliacs. I then said it sounds like a ureteral injury but that I would have been very careful to avoid ureteral injury in resecting the colon. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . Also. IVF’s. I buckled here and proceeded to fail the question. He looked to the junior and said “lets move on to the next question” www. excised the graft and performed an Axbifem. fever and episode of bloody diarrhea. He told me my interventional radiologist agreed and asked what I wanted to do. Stated that the infected graft needed to be removed after a period of AB’s and control of sepsis. etc. I was kind of rattled after that one question in the prior room and it knocked me off my game a little bit. Was about to say I’d get a CT scan as well to r/o abscess but he overrode me and moved up to the next morning and patient had obvious peritonitis. etc.
Response: Few routine questions (risk factors.OdysseyHealth.EXAM 4 March 2004 p7 Comments: This is the only question that I know I failed outright. He tried to end question then but I added very clearly that IF she had a greater than 1cm mass or poor prognostic features such as angio or lymphatic invasion that she would at least be a candidate for adjuvant chemo as well even though nodes were negative. So I don’t know if I scored any points on this question or not. In retrospect. results came back invasive cancer with negative margins.com Odyssey Health Communications. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . I think the CT showed a perigraft abscess rather than just an “infection” and he wanted me to perc drain it and then do a staged procedure like I mentioned later.com Senior Examiner: 35 year old female presents to you with frequent near syncopal episodes. I’ve researched this a little since then and I’m pretty sure that if you control sepsis. Established insulin/glucose ratio c/w insulinoma and then discussed need for preoperative localization and also checked C peptide level to r/o exogenous insulin. Ok. Interruptions before I could finish my train of thought were a common theme in this final room (and really through-out the test) and it tends to prevent examinee from getting all of their points across. which was negative. place your Axbifem and then excise the graft at same operation you can’t be faulted. ongoing surveillance for both breasts and check BRCA level. how are you going to do that? Abdominal CT (negative). He just smiled and didn’t say anything. EUS (negative). He asked about recurrence and need for further operative management and then I realized I’d forgotten to mention postop XRT for her so I gave dissertation on need for XRT after BCT and talked about recurrence rates with that versus mastectomy. Biggest problem with this question was that I just didn’t recognize the infection on CT as an abscess. He gave me a huge hint with the “interventional radiologist” comment but I still didn’t have a clue. Octreotide scan (small blush – mid pancreas) To the OR for www. I would have liked to talk about other options as well – could have discussed partial excisions. I couldn’t believe that I forgot to mention post op XRT but it came up later so I was able to work it back in. Asked for birad level on mammo – told it was a 5. This examiner was very difficult in terms of constant interruptions and never letting me finish a sentence or complete a train of thought. history. Then talked about need to definitively diagnose and so I admitted for 72 hour monitored fast. I also did SNLB. dizziness and a documented low blood glucose with resolution of symptoms once IV glucose given. www. Oh. rerouting of new graft through uninfected tissue – but after screwing the first part up he didn’t want to hear anything else. etc – mom had breast ca at age 35) Looked for palpable mass or evidence systemic disease – none found. Junior Examiner: 42 year old female presents to your office after routine mammography showed microcalcifications in right breast. After doing that. Response: I mentioned obvious suspicion of insulinoma and discussed Whipples Triad very briefly. So I said I’d place her on Tamoxifen.OdysseyHealth. Said based on that we need excisional biopsy and so I said needle localization. stage her. Commentary: This was a straightforward question that I know I passed. which he then asked me to describe. Inc. Went to stereotactic biopsy – atypia only x 2.
6 weeks goes by and no change. Superior Oral Board Results – 90+% pass rates Toll free 877 BE READY . Preoperative localization and intraop management are definitely the things they are most interested in.com www. postoperatively she develops 200cc a day drainage from the drain – checked amylase.EXAM 4 March 2004 p8 exploration – how are you going to do that? Described exposure and mobilization of pancreas and also utilized intraoperative US. Inc. Ok. octreotide and conservative management and that most of these will close with this approach. Detected 3 small lesions – asked for location relevant to main pancreatic duct – not near duct and so I enucleated the 3 lesions and described how I would do that.OdysseyHealth. End of case. he says. Commentary: Pretty straightforward question. I placed a drain in case of pancreatic leak and then was asked is there anything else I would do? I said no – what about re checking your glucose level – I said I guess you could do that but wasn’t sure how reliable that would be. Passed it no trouble. So I checked ERCP – no main duct communication but small side branch – said I would go with endo therapy. very high.com Odyssey Health Communications. Ok. (this was a passing exam) www.OdysseyHealth. Discussed management of pancreatic fistula – TPN.