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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. anal sphincter tone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Meniscus injury; medial most common; pain/swelling; popping sensation
S2-S4

2. most common fx when falling on outsretched hand
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Retrograde ejaculation

3. how ABI help dx of PVD
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

4. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Nonunion and avascular necrosis; fx can block blood supply;
50%; tunneling between rectum or kin
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

5. Valgus and Varus tests
Abd pain and tenderness; bloody diarrhoea or hematochezia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Mammogram

6. beta HCG
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Seminomas

7. inhalation of hot air - steam - smoke in burn victim
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Supraglottic edema; low threshold for intubation

8. Complications of breast impant
Saline and silicone
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Headache - ataxia - bulbar dysfunction

9. How to differentiate ACL and meniscus injury
Carpal tunnel syndrom
Pure motor stroke; limited neurological dysfunction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

10. management of hip fracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Check ET tube placement if correct needle decompresion
If patient ambulatory - surgery and pain control; if not nonop mx

11. varicose veins with ulcer - bleeding and thrombophlebitits
L5 to S2
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

12. What is hungry bone syndrome?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

13. How to confirm achiles tendon rupture
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

14. differential of ultrasound finding of breast mass
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
Saline and silicone
Dm neuropathy; stocking glove pattern
If patient ambulatory - surgery and pain control; if not nonop mx

15. antibiotics of acute cholecystitis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If any compressive symptoms eg. dysphagia
Less than 5mm

16. How to manage obesity
Even after ochiopexy risk of ochiopexy higher then general population
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

17. characteristics of ureteral stone?
Study showed no adverse effect; but they are contraindicated for PVD
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
L5 to S2

18. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Displaced ORIF ; nondisplaced sling immobilization
Headache - ataxia - bulbar dysfunction

19. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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. dorsiflexion and planter flexion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
L5 to S2
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Study showed no adverse effect; but they are contraindicated for PVD

21. 3 mo with groin bulge; bulge appears when child cries
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Amoxicillin-clavulanate
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

22. What is the strongest risk factor for male breast cancer
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Klinefelter syndrome; 50 fold increase;

23. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevated non seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT
Fx displace >1mm - nonunion during followup - osteonecrosis

24. menisci injury
Compression stocking - weight reduction - leg elevation
S2-S4
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

25. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Tendons more likely
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

26. acalculus cholecystitis
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
10-12 months
Carpal tunnel syndrom
Elderly and critically ill patients

27. management of stone 8-10mm
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Amoxicillin-clavulanate

28. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
4-6 weeks for noncontact sports and longer time for contact sports
Brardycardia - HTN - resp depression
MAT; medial meniscus injury; ACL and Tibial colateral ligament

29. Can we use beta blocker for pvd?
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Study showed no adverse effect; but they are contraindicated for PVD
Brardycardia - HTN - resp depression

30. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

31. perioral numbness after parathyroidectomy
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
Pure motor stroke; limited neurological dysfunction
Saline and silicone
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;

32. most frequent complication of TURP
Retrograde ejaculation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
15-40%; self limiting;doesn't require tx
Dumping syndrome; small and frequent meals; no simple sugar

33. beta hcg and AFP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevated non seminomas

34. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
10-12 months
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

35. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

36. Indication for bariatric surgery in obese patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. lacerated wound in palmer surface of hand. what structure is injured?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Tendons more likely

38. When to stop raloxifene before surgery
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If any compressive symptoms eg. dysphagia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Patellar tendon tear; difficulty in extension

39. suprapubic catheterization
When urethral catherization is unsuccessful
Brardycardia - HTN - resp depression
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

40. mx of stress fx
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

41. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cystic scrotal fluid collection between parietal and visceral layers of testis
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. acute colonic ischemia
Headache - ataxia - bulbar dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Progressive fibrosis of palmar fascia. etiololgy not known;
Displaced ORIF ; nondisplaced sling immobilization

43. management of nondisplaced scaphoid fx
Saline and silicone
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

44. surgery for acute cholecystities
If any compressive symptoms eg. dysphagia
L5 to S2
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy

45. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
SAH due to post communicating artery aneurysm;
Ispilateral hypoglossal nerve injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

46. 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
15-40%; self limiting;doesn't require tx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

47. varicocele
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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;
Malignancy until proven otherwise
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

48. 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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

49. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Check ET tube placement if correct needle decompresion
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

50. midline neck swelling moves with protrusion of tongue
Abd pain and tenderness; bloody diarrhoea or hematochezia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery