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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. indication of ursodeoxycholic acid
Helps to dissolve GB cholesterol stone; slowly dissolve in 3 years - symptoms relief in 3 months; for symptomatic gall stones who are poor candidate for surgery
Acute comparment syndrome; increased pain with passive movement of involved muscles; early sensory impairment-decreased vibration sense - two point discrimination - numbness and hypoesthesia; late feature-absent distant pulses
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

2. stress fx
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

3. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
24-48 hours of supportive therapy followed by cholecystectomy
Low anterior resection and radio; add chemo if node positive
Look at pupil; are they small; check ABG; most likely respiratory acidosis due to opioids used for postop pain control; morphine decreases central chemoreceptor sensitivity to C02; although patient has rising C02 his respiratory drive is not working

4. varicose veins with ulcer - bleeding and thrombophlebitits
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Retrograde ejaculation

5. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Subphrenic abscess or other abdominal abscesses; order US or CT

6. mx of stress fx
Tendons more likely
Progressive fibrosis of palmar fascia. etiololgy not known;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check ET tube placement if correct needle decompresion

7. diarrhoea 4-5 days after cholecystectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

8. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Low anterior resection and radio; add chemo if node positive

9. How to evaluate painless testicular swelling suspicious for cancer
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Seminomas

10. tx distal rectal ca
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

11. how hyperventilation lowers ICP
Cystic scrotal fluid collection between parietal and visceral layers of testis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Even after ochiopexy risk of ochiopexy higher then general population
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

12. What is hydrocele?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If patient ambulatory - surgery and pain control; if not nonop mx

13. aspiration of breast cyst is nonbloody
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Brardycardia - HTN - resp depression

14. cremasteric reflex test?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Headache - ataxia - bulbar dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

15. most common fx when falling on outsretched hand
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Carpal tunnel syndrom

16. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

17. Dupuytren contracture
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Progressive fibrosis of palmar fascia. etiololgy not known;

18. When to stop raloxifene before surgery
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

19. How to dx ACL tear?
Ant drawer test; foot placed on exam table; both hand behind knee to push it anteriorly; a difference of 1 cm compared with the opposite side suggests complete ACL tear
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It can take up to 2 weeks to show fx; if high clinical suspicion MRI is ideal test when xray neg - which differentiate ligament injury vs bone fx

20. When do we see complications due to hypophosphatemia
When phosphate levels fall below 1.0; 30% of patient on TPN has this prob; patient develop respiratory weakness - hemolysis - impaired oxygen release from Hb;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Klinefelter syndrome; 50 fold increase;
Meniscus; tenderness medial side of knee - it takes 24hours to form effusion; effusion not bloody; ACL: rapid effusion - most serious form of knee injury; profound pain - inability to ambulate ; popping sensation in both cases

21. severe pain in leg after MVC
Acute comparment syndrome; increased pain with passive movement of involved muscles; early sensory impairment-decreased vibration sense - two point discrimination - numbness and hypoesthesia; late feature-absent distant pulses
Twisting force with the foot fixed on the ground seen in football and basketball games;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
15-40%; self limiting;doesn't require tx

22. What is terrible triad
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
MAT; medial meniscus injury; ACL and Tibial colateral ligament

23. beta HCG
24-48 hours of supportive therapy followed by cholecystectomy
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

24. antibiotics of acute cholecystitis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro

25. dorsiflexion and planter flexion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If patient ambulatory - surgery and pain control; if not nonop mx
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

26. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Abd pain and tenderness; bloody diarrhoea or hematochezia
When phosphate levels fall below 1.0; 30% of patient on TPN has this prob; patient develop respiratory weakness - hemolysis - impaired oxygen release from Hb;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. Can we use beta blocker for pvd?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Study showed no adverse effect; but they are contraindicated for PVD

28. complications of TPN
Dumping syndrome; small and frequent meals; no simple sugar
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevated non seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

29. DD of acute scrotal pain
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

30. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m

31. Why right varicocele is more concerning?

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32. suprapubic catheterization
When urethral catherization is unsuccessful
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Meniscus injury; medial most common; pain/swelling; popping sensation
Check ET tube placement if correct needle decompresion

33. swelling and tenderness in anterior part of knee
Seminomas
Irrigated with normal saline; all deviatlized tissues need to debrided; plain xray to see if there is any FB; wound will be left open and examined for any signs of infection;
Urethral stricture; pelvic of urethral trauma
Patellar tendon tear; difficulty in extension

34. How to confirm dx of compartment syndrom
Elderly and critically ill patients
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Amoxicillin-clavulanate
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

35. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Malignancy until proven otherwise
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
SAH due to post communicating artery aneurysm;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

36. scrotal trauma
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Next best step surgery; not ultrasound
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

37. acute colonic ischemia
Pure motor stroke; limited neurological dysfunction
Right varicocele drains to inferior vena cava; unless patient has obstrction of inf vena cava by intra abdominal mass or big clot from DVT - varicocele doesn't occur; do ct scan to eval caUse of rt varicocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abd pain and tenderness; bloody diarrhoea or hematochezia

38. management of hip fracture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If patient ambulatory - surgery and pain control; if not nonop mx

39. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
SAH due to post communicating artery aneurysm;
Nonunion and avascular necrosis; fx can block blood supply;

40. varicocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Amoxicillin-clavulanate
Unilateral vocal cord paralysis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

41. contraindication of urethral catheterization
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Urethral stricture; pelvic of urethral trauma
Dumping syndrome; small and frequent meals; no simple sugar

42. managment of animal bite in hands
Irrigated with normal saline; all deviatlized tissues need to debrided; plain xray to see if there is any FB; wound will be left open and examined for any signs of infection;
Patellar tendon tear; difficulty in extension
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Strok and traumatic brain injury

43. How to manage obesity
Subphrenic abscess or other abdominal abscesses; order US or CT
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

44. characteristics of ureteral stone?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Subphrenic abscess or other abdominal abscesses; order US or CT
Abd pain and tenderness; bloody diarrhoea or hematochezia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

45. pregnant patient with asymptomatic gall stones
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Amoxicillin-clavulanate
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

46. aspiration of breast cyst is bloody
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Less than 5mm
Mammogram
Even after ochiopexy risk of ochiopexy higher then general population

47. dumping syndrome after gastrectomy
Pulmonary contusion; p/w dyspenoea - tachypnoea - hypoxemia - hemoptysis; decreased breath sound in the affected site; cxr homogenous opacification; mild cases resolve in 3-5 days
Check ET tube placement if correct needle decompresion
Simple breast mass - well circumscribed disappear with aspiraiton; complex cyst; thick walled contain both solid and cystic materials; may need core biopy; solid mass-mostly fibroadenoma-f/you us and biopsy in 6m
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

48. when scaphoid fx patient needs to be referred to orthopedic
L5 to S2
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis

49. What time frame required for bone remodeling
Carpal tunnel syndrom
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Malignancy until proven otherwise
10-12 months

50. ipsilateral deviation of tongue upon protrusion
If any compressive symptoms eg. dysphagia
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Ispilateral hypoglossal nerve injury
Strok and traumatic brain injury