With the vast amount of knowledge that is potentially testable on the ABS Qualifying Exam (QE), it can be hard to see the wood through the trees. In the weeks approaching the ABS QE, one strategy is to focus on studying high-yield topics. But, how do you know what topics are considered high yield?
There are a couple of ways to get an idea of what topic areas are likely to come up on this year’s exam. Firstly, take a look at the ABS QE content outline and try to focus on those topics with higher category weights first. The second thing to do is to look at the SCORE curriculum outline and focus first on the core topics, then the advanced afterwards.
Below, I have chosen 3 questions from TrueLearn’s ABS QE SmartBank for discussion, each of which is from a high-weight category and is a high-yield topic.
Question 1: Inflammatory Brest Cancer
A 55-year-old woman presents to the office with erythema, warmth, and edema over her right breast that has progressed rapidly over the past 3 weeks. A physical exam is negative for breast lesions or axillary lymphadenopathy. Mammography demonstrates only breast skin thickening. A full-thickness skin punch biopsy is performed, revealing the presence of tumor cells within dermal lymphatics. Tumor cells are ER and PR receptor-positive and HER-2 receptor–negative. CT of the chest, abdomen, and pelvis is negative for metastatic disease. What is the best treatment for this patient?
(A) neoadjuvant chemotherapy, lumpectomy with sentinel lymph node biopsy, adjuvant radiation, and endocrine therapy
(B) neoadjuvant chemotherapy, modified radical mastectomy, adjuvant radiation, and endocrine therapy
(C) neoadjuvant chemotherapy, mastectomy with sentinel lymph node biopsy, adjuvant radiation, and endocrine therapy
(D) modified radical mastectomy, adjuvant chemoradiation, and endocrine therapy
(E) chemoradiation and endocrine therapy
Explanation
The correct answer is: B
The patient in this scenario presented with rapid onset of symptoms and a punch biopsy consistent with inflammatory breast cancer. Inflammatory breast cancer is a rare and aggressive form of breast cancer that manifests clinically with edema and a Peau d’orange (orange peel) appearance.
Diagnostic criteria for inflammatory breast cancer include the acute onset of symptoms (i.e., erythema, warmth, and edema) for a duration of < 6 months and a pathologic confirmation via either biopsy demonstrating invasive carcinoma (if a lesion is present) or full-thickness skin punch biopsy demonstrating the presence of tumor cells within dermal lymphatics.
Treatment of inflammatory breast cancer is multimodal, with neoadjuvant chemotherapy, modified radical mastectomy, and adjuvant radiation with endocrine therapy for ER-positive tumors or trastuzumab for HER-positive receptors. The patient in this scenario had an ER-positive tumor and should therefore receive endocrine therapy but had an HER-negative tumor and would not benefit from trastuzumab.
Inflammatory breast cancer with erythema and edema of the breast as well as dimpling of the breast tissue.
Answer A: There is no role for breast-conserving therapy in the setting of inflammatory breast cancer, even in the presence of a strong response to neoadjuvant chemotherapy.
Answer C: Sentinel lymph node biopsy is contraindicated in the presence of inflammatory breast cancer because tumor cells may plug the dermal lymphatics and thus make sentinel node mapping impossible. Formal axillary dissection is required, even in the absence of clinically positive nodes.
Answer D: Neoadjuvant chemotherapy is essential to the treatment of inflammatory breast cancer. The rationale is to reduce tumor burden and facilitate surgical resection.
Answer E: Mastectomy improves locoregional control, disease-free survival, and cancer-specific survival in patients with inflammatory breast cancer when compared to those who received chemoradiotherapy alone.
Bottom Line: Multimodal therapy, including neoadjuvant chemotherapy, modified radical mastectomy, adjuvant radiation therapy, and hormonal therapy, is recommended for the treatment of inflammatory breast cancer.
TrueLearn Insight : Peau d’orange or orange peel appearance is a buzzword often used to describe the characteristic edema and dimpling of breast tissue seen in patients with inflammatory breast cancer.
For more information, see:
Barbie TU, Gillanders WE. Chapter 74: Breast Disease. In: Mulholland MW, ed. Greenfield’s Surgery: Scientific Principles & Practice. 6th ed. Wolters Kluwer; 2016:1291-1339.
Discussion
Breast cancer has been a consistent high yield topic on the exam over many years. It usually appears in a way to test knowledge of the multimodality treatments that are used. The answer choices are often very similar to one another and can therefore become confusing.
The best way to approach these questions is to break down the treatments into 4 types: surgery (breast, nodal), chemotherapy (neoadjuvant, adjuvant), radiation (adjuvant), and hormonal therapy (adjuvant). From there, for each treatment, work through the indications and contraindications for each treatment to help you figure out a yes/no for each one. If there is a contraindication, the question stem will tell you. A common one is a history of scleroderma or prior radiation as contraindications to radiation therapy.
The table below will help you to categorize patients.
Memorizing this table will allow you to save time and simplify answering the question.
Question 2: Cardiogenic Shock
A Swan-Ganz catheter is placed into a dialysis-dependent patient with cold, clammy skin. The readings show a pulse rate of 94/min, with a cardiac index of 1.5 L/min/m2, a pulmonary capillary wedge pressure of 20 mm Hg, and systemic vascular resistance of 3000 dynes/sec/cm-5. Which of the following is the best management option for the patient?
(A) norepinephrine and IV antibiotics
(B) milrinone
(C) dobutamine
(D) rapid infusion of 2 liters of crystalloid
(E) IV hydrocortisone
Explanation
The correct answer is: C
The readings from the Swan-Ganz catheter suggest the patient is in cardiogenic shock. Listed below are the normal ranges for the cardiac index, pulmonary capillary wedge pressure, and systemic vascular resistance. The best medical management for cardiogenic shock is the addition of a contractility agent, such as dobutamine.
The patient is dialysis-dependent. Milrinone is relatively contraindicated in patients with kidney failure.
Answer A: Norepinephrine is the initial vasopressor of choice in septic and could be considered in cardiogenic shock. However, IV antibiotics would be an appropriate treatment option for a patient in septic shock. Septic shock would show a low systemic vascular resistance.
Answer B: The patient is dialysis-dependent, and milrinone is relatively contraindicated in patients with kidney failure as it is renally cleared. In dialysis-dependent patients, its blood levels can rise precipitously and cause severe hypotension.
Answer D: Rapid infusion of crystalloid would be an appropriate treatment for hypovolemic shock. Hypovolemic shock would show a low pulmonary capillary wedge pressure, whereas this patient has an elevated wedge pressure, which makes hypovolemia unlikely.
Answer E: IV hydrocortisone is appropriate to treat a patient with adrenal insufficiency. A patient with acute adrenal insufficiency would typically have an increased cardiac index and decreased systemic vascular resistance.
Bottom Line: Cardiogenic shock is treated with a contractility agent and by fixing the primary coronary problem, like percutaneous coronary intervention for acute myocardial infarction.
For more information, see:
Use of vasopressors and inotropes: UpToDate
Discussion
There is usually a question or two on the exam about the diagnosis and/or treatment of shock. The easiest way to approach this kind of question, if it gives you values from the Swan-Ganz catheter, is to work out the type of shock first, and then decide on the most appropriate first-line treatment.
Memorizing the table below is key to answering these questions in a speedy manner as these questions can become confusing on exam day.
Question 3: Anterior Stab Wound
A 36-year-old male chef is brought to the trauma bay after accidentally stabbing himself at work with a paring knife. He has a 2-cm stab wound to the right of his umbilicus. He is hemodynamically stable. His examination is significant for localized tenderness around the wound without signs of peritonitis. Local wound exploration demonstrates possible violation of the anterior abdominal fascia, but it is not clear if the patient’s peritoneal cavity has been violated due to his body habitus. Which of the following is the best course of action?
(A) discharge from trauma bay
(B) admission for serial abdominal exams
(C) diagnostic peritoneal lavage
(D) CT scan of abdomen and pelvis
(E) exploratory laparotomy
Explanation
The correct answer is: B
The question presents a scenario of an anterior abdominal stab wound. The anterior abdomen is the area from the costal margins to the inguinal ligaments between the anterior axillary lines (see image).
Abdominal anatomy with the anterior abdomen bounded by asterisks.
Data have shown that anterior stab wounds only violate the peritoneal cavity a minority of the time (approximately 25-33%). Even in patients with peritoneal penetration, only 50% will present with indications for a laparotomy. In the remaining 50%, only half will become symptomatic and require a laparotomy. Thus, a push has been made in the past few decades for selective nonoperative management of anterior abdominal stab wounds to avoid the morbidity of non-therapeutic laparotomy.
A local wound exploration under semi-sterile conditions is the first step. If it can be confirmed that violation of the anterior abdominal fascia has not occurred, the wound is irrigated, a tetanus immunization is administered, and the patient is discharged. In most centers, a hemodynamically stable patient without peritonitis with penetration of the anterior aponeurosis or peritoneum will undergo serial physical examinations for 24 hours. Almost all patients with continued intraperitoneal bleeding or peritonitis from hollow viscus injury will become symptomatic within 6 to 16 hours, which should then prompt laparotomy.
The incidence of obesity is increasing in the population and therefore is encountered more often in the trauma population. At times, abdominal examinations may be difficult in obese patients. However, the physician is still able to detect the presence or absence of peritoneal signs either by palpation or percussion. On the other hand, local wound exploration is usually done in the trauma bay of the ER with less than ideal lighting and usually uses a small incision in which the surgeon is trying to navigate through several centimeters of adipose tissue in an obese patient to see the fascia and therefore may not see any violation clearly.
A study by Bloom et al. in 2015 concluded that admission and serial abdominal examinations (looking for signs of peritonitis or worsening of findings) in obese trauma patients who were the victims of penetrating abdominal traumas is a preferred approach to immediate exploratory laparotomy, which is preferred in thinner trauma patients who had suffered penetrating abdominal trauma.
Answer A: Discharge from the trauma bay without observation would be inappropriate in this patient. If the patient’s anterior abdominal fascia were confirmed to be intact, discharge from the trauma bay would be acceptable.
Answer C: Diagnostic peritoneal lavage (DPL) involves lavaging the peritoneal cavity with warm saline through a small incision made around the umbilicus to determine if there are any intra-abdominal injuries. Enthusiasm for DPL has waned over time due to inexperience in many centers and the possibility of false-positive results from intraperitoneal blood related to injury to the anterior abdominal wall. The focused assessment with sonography for trauma (FAST) exam has largely replaced the use of DPL in most centers.
Answer D: CT scan is utilized in cases where the patient is not alert and able to undergo a reliable abdominal examination. In many cases, it can show a fascial defect but not in all cases (depending on body habitus and CT scan resolution). This patient is able to undergo serial abdominal examinations to show any degree of peritonitis.
Answer E: In the past few decades, selective nonoperative management of anterior stab wounds in hemodynamically stable patients without signs of peritonitis has become standard of care to avoid the morbidity of non-therapeutic laparotomy. Exploratory laparotomy is reserved for anterior stab wound patients who are hemodynamically unstable or have signs of peritonitis.
Bottom Line: Selective nonoperative management of anterior stab wounds in hemodynamically stable patients without signs of peritonitis has become standard of care to avoid the morbidity of non-therapeutic laparotomy. If the anterior abdominal fascia has been violated on local wound exploration, admission for serial abdominal examinations is the preferred course of action.
For more information, see:
Feliciano DV. Penetrating abdominal trauma. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 13th ed. Philadelphia, PA: Elsevier; 2020:1162-1166.
Image source: Wikimedia Commons
Discussion
Trauma is always a high yield topic on the exam. The most frequently asked questions tend to involve some sort of either blunt or penetrating abdominal trauma, or a polytrauma, and which order to do what interventions in. In general, for trauma questions, stick to the ABCs. Trauma is fairly algorithmic, and as long as you stick to the algorithm, you can’t go too far wrong.
The other important thing in trauma questions is to figure out whether or not the patient is hemodynamically stable, and if not, decide on the most important reason for their instability, ie, what will kill them the fastest, and address that first. This is ALWAYS bleeding. Even in cases of head/spinal injury, you need to rule out bleeding first. Usually in these types of questions the correct answer is an emergent intervention, whether that be a chest tube in the ED or a laparotomy in the OR.
In the trauma patient who is hemodynamically stable, such as in this question, you have more time to do other diagnostic interventions. The next question is: does he have anything that is an absolute indication for emergent OR? That would be generalized peritonitis, persistent hemodynamic instability despite resuscitation, or evisceration. In this case, no, he doesn’t. He therefore meets criteria for local wound exploration; however, this proved non-diagnostic.
At this point, it isn’t safe to discharge the patient because we can’t definitively rule out intraperitoneal injury. A laparotomy is very morbid for a patient with no absolute indications at this time so we can hold off on this too. The most likely organ to be injured is the small bowel, and unfortunately CT scans are notoriously non-diagnostic for hollow viscus injury; therefore, this would not be a good step. DPL is not used in penetrating trauma, but instead in blunt abdominal trauma with an equivocal FAST exam. This is very rarely used nowadays. That leaves us with serial abdominal exams, which we usually perform for a 24-hour period, as the majority of patients with a hollow viscus injury will develop peritonitis within the first 6-8 hours after injury.
Postscript
Thank you for reading my brief blog post. I hope that it was useful to you. Here are a few pearls of advice from my experience taking the exam.
1. Know common indications and contraindications for high yield disease management options.
2. The exam will allow you to eliminate/select treatments based on key buzzwords in the question stem. If you are stuck eliminating an answer choice, go back to the stem and take a look again.
3. Save memorization topics until nearer the exam (eg, antibiotics for certain criteria, mechanism of action of medications, mutation inheritance patterns) as they will stay fresher in your mind.
For hundreds of other high-yield ABS QE practice questions, along with authoritative answer explanations, illustrative figures and tables, supporting references, focused Bottom Line statements, and test-taking tips, check out TrueLearn’s ABS QE SmartBank.
The author would like to acknowledge Ben Shragge for contributions made to this post.
Evidence
Blog