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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. most common complication of acute cholecystitis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dm neuropathy; stocking glove pattern
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

2. differential of ultrasound finding of breast mass
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

3. recurrent laryngeal nerve injury
Seminomas
ACL injury
Unilateral vocal cord paralysis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

4. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
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

5. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Strok and traumatic brain injury
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
Saline and silicone

6. Complications of breast impant
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

7. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Ispilateral hypoglossal nerve injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

8. beta hcg and AFP
Elevated non seminomas
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Klinefelter syndrome; 50 fold increase;
Pure motor stroke; limited neurological dysfunction

9. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

10. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Meniscus injury; medial most common; pain/swelling; popping sensation

11. inhalation of hot air - steam - smoke in burn victim
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Supraglottic edema; low threshold for intubation

12. first step for evaluation of testicular swelling
Retrograde ejaculation
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

13. popping sensation; rapid onset of knee effusion. athelet
Compression stocking - weight reduction - leg elevation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
ACL injury
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;

14. stress fx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Brardycardia - HTN - resp depression

15. first line of management of PVD
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Next best step surgery; not ultrasound
Subphrenic abscess or other abdominal abscesses; order US or CT

16. How to confirm achiles tendon rupture
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If patient ambulatory - surgery and pain control; if not nonop mx

17. varicocele
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dumping syndrome; small and frequent meals; no simple sugar

18. most common fx when falling on outsretched hand
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

19. suprapubic catheterization
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful
Displaced ORIF ; nondisplaced sling immobilization
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

20. most frequent complication of TURP
Subphrenic abscess or other abdominal abscesses; order US or CT
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Retrograde ejaculation

21. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

22. acute colonic ischemia
Less than 5mm
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
SAH due to post communicating artery aneurysm;
Abd pain and tenderness; bloody diarrhoea or hematochezia

23. cremasteric reflex test?
Meniscus injury; medial most common; pain/swelling; popping sensation
Cystic scrotal fluid collection between parietal and visceral layers of testis
Check ET tube placement if correct needle decompresion
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

24. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Ispilateral hypoglossal nerve injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

25. aspiration of breast cyst is bloody
Next best step surgery; not ultrasound
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mammogram
Saline and silicone

26. lacunar stroke
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pure motor stroke; limited neurological dysfunction

27. management of gunshot wound
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

28. menisci injury
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
Headache - ataxia - bulbar dysfunction
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Twisting force with the foot fixed on the ground seen in football and basketball games;

29. How to dx ACL tear?
Pure motor stroke; limited neurological dysfunction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

30. ct scan; cystic lesion in head of pancreas; next step
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.
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis

31. Dupuytren contracture
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
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia
Progressive fibrosis of palmar fascia. etiololgy not known;

32. when scaphoid fx patient needs to be referred to orthopedic
CRPS
Fx displace >1mm - nonunion during followup - osteonecrosis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

33. complications of TPN
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Compression stocking - weight reduction - leg elevation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

34. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. varicose veins with ulcer - bleeding and thrombophlebitits
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

36. How varicocele causes testicular atrophy
Retrograde ejaculation
Fx displace >1mm - nonunion during followup - osteonecrosis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. diarrhoea 4-5 days after cholecystectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Fx displace >1mm - nonunion during followup - osteonecrosis
Dumping syndrome; small and frequent meals; no simple sugar

38. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

39. What is prehn sign?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Retrograde ejaculation
CRPS
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

40. dorsiflexion and planter flexion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
L5 to S2
Retrograde ejaculation
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

41. When do we see complications due to hypophosphatemia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Urethral stricture; pelvic of urethral trauma
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

42. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ispilateral hypoglossal nerve injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

43. 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
If any compressive symptoms eg. dysphagia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

44. when patient with severe lung disease have C02 retention
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

45. 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)
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;
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

46. lacerated wound in palmer surface of hand. what structure is injured?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elevated non seminomas
Tendons more likely
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

47. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Nonunion and avascular necrosis; fx can block blood supply;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Strok and traumatic brain injury

48. tx distal rectal ca
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elderly and critically ill patients

49. scrotal trauma
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound
L5 to S2
Nonunion and avascular necrosis; fx can block blood supply;

50. surgery for acute cholecystities
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Seminomas
24-48 hours of supportive therapy followed by cholecystectomy