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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. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Compression stocking - weight reduction - leg elevation
Displaced ORIF ; nondisplaced sling immobilization
Dm neuropathy; stocking glove pattern
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

2. What is the contraindication of hyperventilation in inc ICP
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Strok and traumatic brain injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

3. When goiter needs surgery
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
4-6 weeks for noncontact sports and longer time for contact sports
If any compressive symptoms eg. dysphagia
Cystic scrotal fluid collection between parietal and visceral layers of testis

4. What is the complications of undescended testis
Patellar tendon tear; difficulty in extension
Amoxicillin-clavulanate
Even after ochiopexy risk of ochiopexy higher then general population
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

5. mangement of localized lymphadenopathy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Seminomas
Compression stocking - weight reduction - leg elevation

6. acalculus cholecystitis
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Elderly and critically ill patients
Seminomas
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

7. complications of TPN
Saline and silicone
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
S2-S4

8. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Progressive fibrosis of palmar fascia. etiololgy not known;
Subphrenic abscess or other abdominal abscesses; order US or CT
Nonunion and avascular necrosis; fx can block blood supply;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

9. midline neck swelling moves with protrusion of tongue
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;

10. What types of breast implants are available
Patellar tendon tear; difficulty in extension
S2-S4
Saline and silicone
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

11. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Even after ochiopexy risk of ochiopexy higher then general population
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
15-40%; self limiting;doesn't require tx

12. How to differentiate ACL and meniscus injury
Amoxicillin-clavulanate
If patient ambulatory - surgery and pain control; if not nonop mx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

13. popping sensation; rapid onset of knee effusion. athelet
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury
ACL injury
Dm neuropathy; stocking glove pattern

14. mx of stress 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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

15. Why ruq calcificaion is concerning
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
SAH due to post communicating artery aneurysm;

16. How mcmurray manuver perform
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
Brardycardia - HTN - resp depression
ACL injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

17. aspiration of breast cyst is nonbloody
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

18. Incidence of AF in CABG patient

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19. When do we see complications due to hypophosphatemia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Carpal tunnel syndrom
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;
4-6 weeks for noncontact sports and longer time for contact sports

20. menisci injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Twisting force with the foot fixed on the ground seen in football and basketball games;
Tendons more likely
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

21. suprapubic catheterization
Abd pain and tenderness; bloody diarrhoea or hematochezia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
When urethral catherization is unsuccessful

22. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Meniscus injury; medial most common; pain/swelling; popping sensation
L5 to S2
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

23. types of hip fracture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

24. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Ispilateral hypoglossal nerve injury
Klinefelter syndrome; 50 fold increase;
Strok and traumatic brain injury

25. How to evaluate painless testicular swelling suspicious for cancer
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Study showed no adverse effect; but they are contraindicated for PVD
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

26. differential of ultrasound finding of breast mass
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

27. tx distal rectal ca
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Compression stocking - weight reduction - leg elevation

28. acute colonic ischemia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check ET tube placement if correct needle decompresion
When urethral catherization is unsuccessful

29. clavicle fx
Seminomas
Patellar tendon tear; difficulty in extension
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Displaced ORIF ; nondisplaced sling immobilization

30. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury
Saline and silicone

31. several knee pain after being tackled in football game
Mammogram
Amoxicillin-clavulanate
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

32. painless testicular mass in young male
Brardycardia - HTN - resp depression
Malignancy until proven otherwise
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

33. perioral numbness after parathyroidectomy
Amoxicillin-clavulanate
Elderly and critically ill patients
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

34. complication displaced or communited distal radial fx
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;
Carpal tunnel syndrom
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
50%; tunneling between rectum or kin

35. cremasteric reflex
24-48 hours of supportive therapy followed by cholecystectomy
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Amoxicillin-clavulanate

36. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dm neuropathy; stocking glove pattern
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
SAH due to post communicating artery aneurysm;
Carpal tunnel syndrom

37. SOB - confusion - petechial rash after trauma - fracture
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;

38. what size of ureteral stone for non op mx
Less than 5mm
Meniscus injury; medial most common; pain/swelling; popping sensation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

39. Complications of breast impant
Twisting force with the foot fixed on the ground seen in football and basketball games;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abd pain and tenderness; bloody diarrhoea or hematochezia

40. What is prehn sign?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

41. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Next best step surgery; not ultrasound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

42. characteristics of ureteral stone?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

43. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elderly and critically ill patients
Mammogram
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

44. What time frame required for bone remodeling
10-12 months
SAH due to post communicating artery aneurysm;
Urethral stricture; pelvic of urethral trauma
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

45. when scaphoid fx patient needs to be referred to orthopedic
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Less than 5mm
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Fx displace >1mm - nonunion during followup - osteonecrosis

46. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Retrograde ejaculation

47. What are the common injuries from lightning?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Check ET tube placement if correct needle decompresion
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

48. most common complication of acute cholecystitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Subphrenic abscess or other abdominal abscesses; order US or CT

49. lacerated wound in palmer surface of hand. what structure is injured?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Tendons more likely

50. diarrhoea 4-5 days after cholecystectomy
Klinefelter syndrome; 50 fold increase;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid