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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. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Check ET tube placement if correct needle decompresion

2. How to manage a patient with asystole
When urethral catherization is unsuccessful
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Carpal tunnel syndrom

3. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
L5 to S2
Low anterior resection and radio; add chemo if node positive
CRPS
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

4. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

5. When patient can go back to sports after clavicle fx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
4-6 weeks for noncontact sports and longer time for contact sports
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

6. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Ispilateral hypoglossal nerve injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

7. Indication for bariatric surgery in obese patients
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound

8. managment of animal bite in hands
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;
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;

9. varicose veins with ulcer - bleeding and thrombophlebitits
Seminomas
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Fx displace >1mm - nonunion during followup - osteonecrosis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

10. Tx of pulmonary contusion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

11. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
If patient ambulatory - surgery and pain control; if not nonop mx

12. most common fx when falling on outsretched hand
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

13. 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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Even after ochiopexy risk of ochiopexy higher then general population
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

14. 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
Klinefelter syndrome; 50 fold increase;
Brardycardia - HTN - resp depression
ACL injury

15. cat/dog bites
Twisting force with the foot fixed on the ground seen in football and basketball games;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Amoxicillin-clavulanate

16. How to confirm achiles tendon rupture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Carpal tunnel syndrom
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

17. What is terrible triad
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Progressive fibrosis of palmar fascia. etiololgy not known;

18. anal sphincter tone
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
S2-S4

19. What types of breast implants are available
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Saline and silicone
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
When urethral catherization is unsuccessful

20. 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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

21. What is cushing's triad
Brardycardia - HTN - resp depression
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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 full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

22. clavicle fx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Displaced ORIF ; nondisplaced sling immobilization
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

23. How varicocele causes testicular atrophy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Headache - ataxia - bulbar dysfunction
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

24. complication displaced or communited distal radial fx
L5 to S2
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

25. midline neck swelling moves with protrusion of tongue
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Unilateral vocal cord paralysis

26. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

27. Patient underwent CABG; postoperatively drowsy. most likely cause?
CRPS
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

28. diarrhoea 4-5 days after cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Next best step surgery; not ultrasound
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

29. 3 mo with groin bulge; bulge appears when child cries
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

30. How to dx ACL tear?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Study showed no adverse effect; but they are contraindicated for PVD
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
ACL injury

31. acalculus cholecystitis
Carpal tunnel syndrom
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elderly and critically ill patients
Retrograde ejaculation

32. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Progressive fibrosis of palmar fascia. etiololgy not known;
Meniscus injury; medial most common; pain/swelling; popping sensation

33. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Epi and chest compressio for prolong period of time; atropine is given after epi;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
15-40%; self limiting;doesn't require tx

34. diarrhoea after gastric bypass
Saline and silicone
Carpal tunnel syndrom
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
Dumping syndrome; small and frequent meals; no simple sugar

35. types of hip fracture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

36. Why initial xrays are negative in scaphoid fx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Study showed no adverse effect; but they are contraindicated for PVD

37. 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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Study showed no adverse effect; but they are contraindicated for PVD

38. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Less than 5mm

39. varicocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

40. What time frame required for bone remodeling
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
10-12 months
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

41. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dumping syndrome; small and frequent meals; no simple sugar
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

42. when scaphoid fx patient needs to be referred to orthopedic
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fx displace >1mm - nonunion during followup - osteonecrosis
Subphrenic abscess or other abdominal abscesses; order US or CT

43. severe pain in leg after MVC
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
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
Klinefelter syndrome; 50 fold increase;

44. tx distal rectal ca
Retrograde ejaculation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

45. What is the strongest risk factor for male breast cancer
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Subphrenic abscess or other abdominal abscesses; order US or CT
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Klinefelter syndrome; 50 fold increase;

46. lacerated wound in palmer surface of hand. what structure is injured?
Pure motor stroke; limited neurological dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Tendons more likely

47. What is hungry bone syndrome?
Strok and traumatic brain injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
4-6 weeks for noncontact sports and longer time for contact sports

48. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dumping syndrome; small and frequent meals; no simple sugar

49. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Klinefelter syndrome; 50 fold increase;
Compression stocking - weight reduction - leg elevation
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. When to do surgery in undesceneded testis?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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