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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.
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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. Why ruq calcificaion is concerning
Mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Next best step surgery; not ultrasound
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

2. most frequent complication of TURP
Brardycardia - HTN - resp depression
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Retrograde ejaculation

3. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Tendons more likely
Dumping syndrome; small and frequent meals; no simple sugar
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;

4. 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
Dm neuropathy; stocking glove pattern
Unilateral vocal cord paralysis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

5. management of nondisplaced scaphoid fx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Epi and chest compressio for prolong period of time; atropine is given after epi;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

6. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Compression stocking - weight reduction - leg elevation
Less than 5mm

7. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Study showed no adverse effect; but they are contraindicated for PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

8. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ACL injury
24-48 hours of supportive therapy followed by cholecystectomy

9. management of stone 8-10mm
Elevated non seminomas
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

10. SOB - confusion - petechial rash after trauma - fracture
50%; tunneling between rectum or kin
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

11. When goiter needs surgery
Pure motor stroke; limited neurological dysfunction
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
If any compressive symptoms eg. dysphagia

12. what size of ureteral stone for non op mx
Less than 5mm
Ispilateral hypoglossal nerve injury
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

13. managment of animal bite in hands
Dumping syndrome; small and frequent meals; no simple sugar
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
Mammogram

14. most common complication of acute cholecystitis
Check ET tube placement if correct needle decompresion
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
If any compressive symptoms eg. dysphagia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

15. ct scan; cystic lesion in head of pancreas; next step
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Tendons more likely

16. When patient can go back to sports after clavicle fx
Dm neuropathy; stocking glove pattern
4-6 weeks for noncontact sports and longer time for contact sports
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Progressive fibrosis of palmar fascia. etiololgy not known;

17. characteristics of ureteral stone?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cystic scrotal fluid collection between parietal and visceral layers of testis

18. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Fx displace >1mm - nonunion during followup - osteonecrosis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

19. clavicle fx
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
Displaced ORIF ; nondisplaced sling immobilization
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS

20. What is terrible triad
Even after ochiopexy risk of ochiopexy higher then general population
When urethral catherization is unsuccessful
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Displaced ORIF ; nondisplaced sling immobilization

21. Valgus and Varus tests
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Amoxicillin-clavulanate
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

22. when patient with severe lung disease have C02 retention
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
Brardycardia - HTN - resp depression
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Unilateral vocal cord paralysis

23. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Less than 5mm
Meniscus injury; medial most common; pain/swelling; popping sensation
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

24. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

25. lacunar stroke
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pure motor stroke; limited neurological dysfunction
Compression stocking - weight reduction - leg elevation
Dumping syndrome; small and frequent meals; no simple sugar

26. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

27. Why varicocele more common in the left side
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

28. varicocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Seminomas
Brardycardia - HTN - resp depression
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

29. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
If patient ambulatory - surgery and pain control; if not nonop mx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

30. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Progressive fibrosis of palmar fascia. etiololgy not known;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

31. sudden onset of postoperative hyperglycemia when patient on TPN
S2-S4
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Patellar tendon tear; difficulty in extension

32. What types of breast implants are available
When urethral catherization is unsuccessful
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Saline and silicone
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

33. What is the strongest risk factor for male breast cancer
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;
Klinefelter syndrome; 50 fold increase;
Seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

34. Most common of sudden death due to steering wheel injury
Meniscus injury; medial most common; pain/swelling; popping sensation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

35. cremasteric reflex test?
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
10-12 months
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

36. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Dumping syndrome; small and frequent meals; no simple sugar
Urethral stricture; pelvic of urethral trauma
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

37. anal sphincter tone
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
S2-S4
Patellar tendon tear; difficulty in extension

38. How to perform lachman test
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ispilateral hypoglossal nerve injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

39. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion
Nonunion and avascular necrosis; fx can block blood supply;
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

40. menisci injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

41. How to confirm achiles tendon rupture
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

42. When to do surgery in undesceneded testis?
S2-S4
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

43. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

44. Why right varicocele is more concerning?

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45. common complication of inadequate mx of scaphoid fx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Nonunion and avascular necrosis; fx can block blood supply;

46. diarrhoea 4-5 days after cholecystectomy
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;
Ispilateral hypoglossal nerve injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

47. What is cushing's triad
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Brardycardia - HTN - resp depression
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Retrograde ejaculation

48. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

49. dorsiflexion and planter flexion
Abd pain and tenderness; bloody diarrhoea or hematochezia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
L5 to S2

50. aspiration of breast cyst is bloody
Mammogram
Tendons more likely
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur