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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. DD of acute scrotal pain
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Mammogram
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

2. Why initial xrays are negative in scaphoid fx
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
Dumping syndrome; small and frequent meals; no simple sugar
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

3. transrectal prostate biopsy
Brardycardia - HTN - resp depression
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

4. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

5. tx distal rectal ca
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Nonunion and avascular necrosis; fx can block blood supply;

6. common complication of inadequate mx of scaphoid fx
BMI<40 for low risk patient and >35 ofr high risk with obesity related comorbidites like OSA - OA - LBP - HTN - HLD; BMI >35 have high risk of complications and need to be managed aggresssively;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Nonunion and avascular necrosis; fx can block blood supply;
SAH due to post communicating artery aneurysm;

7. surgery for acute cholecystities
Sphincter sparing surgery (local resection) - abdomnio perineal resection
L5 to S2
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
24-48 hours of supportive therapy followed by cholecystectomy

8. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Meniscus injury; medial most common; pain/swelling; popping sensation

9. several knee pain after being tackled in football game
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

10. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dumping syndrome; small and frequent meals; no simple sugar
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Even after ochiopexy risk of ochiopexy higher then general population

11. complications of TPN
Ispilateral hypoglossal nerve injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4-6 weeks for noncontact sports and longer time for contact sports

12. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
CRPS
Malignancy until proven otherwise

13. Why ruq calcificaion is concerning
4-6 weeks for noncontact sports and longer time for contact sports
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Carpal tunnel syndrom
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

14. popping sensation; rapid onset of knee effusion. athelet
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
ACL injury
CRPS
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

15. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dm neuropathy; stocking glove pattern
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

16. diarrhoea after gastric bypass
Study showed no adverse effect; but they are contraindicated for PVD
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

17. cat/dog bites
Meniscus injury; medial most common; pain/swelling; popping sensation
Amoxicillin-clavulanate
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

18. midline neck swelling moves with protrusion of tongue
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
ACL injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

19. Tx of proximal non metastatic rectal ca
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;
Low anterior resection and radio; add chemo if node positive
S2-S4
ACL injury

20. differential of ultrasound finding of breast mass
Subphrenic abscess or other abdominal abscesses; order US or CT
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
If any compressive symptoms eg. dysphagia

21. pregnant patient with asymptomatic gall stones
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Unilateral vocal cord paralysis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

22. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
S2-S4
Brardycardia - HTN - resp depression
Urethral stricture; pelvic of urethral trauma

23. cremasteric reflex
Dumping syndrome; small and frequent meals; no simple sugar
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Malignancy until proven otherwise
10-12 months

24. acalculus cholecystitis
Elderly and critically ill patients
Dumping syndrome; small and frequent meals; no simple sugar
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

25. recurrent laryngeal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar
Abd pain and tenderness; bloody diarrhoea or hematochezia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Unilateral vocal cord paralysis

26. what size of ureteral stone for non op mx
Less than 5mm
Even after ochiopexy risk of ochiopexy higher then general population
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;
Malignancy until proven otherwise

27. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Saline and silicone
If they are given excess glucose; glucose produces more C02 for each liter of 02 than other two nutrients; excessive C02 causes hypercapnia; weaning from ventilation will be difficult
If patient ambulatory - surgery and pain control; if not nonop mx

28. most frequent complication of TURP
Retrograde ejaculation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
L5 to S2

29. anal sphincter tone
Urethral stricture; pelvic of urethral trauma
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
S2-S4
Less than 5mm

30. characteristics of ureteral stone?
L5 to S2
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Study showed no adverse effect; but they are contraindicated for PVD

31. Why right varicocele is more concerning?

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32. Patient underwent CABG; postoperatively drowsy. most likely cause?
Strok and traumatic brain injury
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
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
Twisting force with the foot fixed on the ground seen in football and basketball games;

33. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
S2-S4
Urethral stricture; pelvic of urethral trauma
SAH due to post communicating artery aneurysm;
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

34. What percent of anal abscess deveolop fisutula
When urethral catherization is unsuccessful
50%; tunneling between rectum or kin
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

35. What types of breast implants are available
Saline and silicone
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

36. Valgus and Varus tests
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Urethral stricture; pelvic of urethral trauma

37. types of hip fracture
4-6 weeks for noncontact sports and longer time for contact sports
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
L5 to S2

38. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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;
ACL injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

39. perioral numbness after parathyroidectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Amoxicillin-clavulanate
Hypocalcemia; other signs are muscle cramps - carpopedal spasm; postive chvostek sign (ipsilateral contraction of facial muscles on tapping the angle of jaw) trousseau sign (rapid carpopedal spasm on occlusion of blood supply to upper extremity
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

40. mx of stress fx
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

41. ipsilateral deviation of tongue upon protrusion
Hypocalcemia; other signs are muscle cramps - carpopedal spasm; postive chvostek sign (ipsilateral contraction of facial muscles on tapping the angle of jaw) trousseau sign (rapid carpopedal spasm on occlusion of blood supply to upper extremity
Pt hemodynamically stable and no sign of peritonitis: Ct scan ;unstable with sign of peritonitis - possible organ evicsceration (blood in urine) immediate laparatomy; most patients go for laparotomy
Ispilateral hypoglossal nerve injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

42. management of hip fracture
Pure motor stroke; limited neurological dysfunction
When urethral catherization is unsuccessful
If patient ambulatory - surgery and pain control; if not nonop mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

43. management of stone 8-10mm
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Thompson test; squeeszing of calf muscle cause plantar flexion; absence confirms dx; absence of active plantar flexion not reliable since patient can use accessory muscles

44. dumping syndrome after gastrectomy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If they are given excess glucose; glucose produces more C02 for each liter of 02 than other two nutrients; excessive C02 causes hypercapnia; weaning from ventilation will be difficult
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

45. Indication for bariatric surgery in obese patients
BMI<40 for low risk patient and >35 ofr high risk with obesity related comorbidites like OSA - OA - LBP - HTN - HLD; BMI >35 have high risk of complications and need to be managed aggresssively;
Malignancy until proven otherwise
Unilateral vocal cord paralysis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

46. Dupuytren contracture
Twisting force with the foot fixed on the ground seen in football and basketball games;
Seminomas
Nonunion and avascular necrosis; fx can block blood supply;
Progressive fibrosis of palmar fascia. etiololgy not known;

47. Why varicocele more common in the left side
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
Nonunion and avascular necrosis; fx can block blood supply;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Brardycardia - HTN - resp depression

48. What is hungry bone syndrome?
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Retrograde ejaculation

49. swelling and tenderness in anterior part of knee
Unilateral vocal cord paralysis
If they are given excess glucose; glucose produces more C02 for each liter of 02 than other two nutrients; excessive C02 causes hypercapnia; weaning from ventilation will be difficult
Patellar tendon tear; difficulty in extension
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

50. SOB - confusion - petechial rash after trauma - fracture
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
S2-S4