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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. managment of animal bite in hands
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;
When urethral catherization is unsuccessful
Brardycardia - HTN - resp depression
Supraglottic edema; low threshold for intubation

2. first line of management of PVD
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

3. severe pain in leg after MVC
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
Saline and silicone
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
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

4. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

5. transrectal prostate biopsy
Brardycardia - HTN - resp depression
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

6. tx distal rectal ca
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Study showed no adverse effect; but they are contraindicated for PVD

7. most frequent complication of TURP
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Ispilateral hypoglossal nerve injury

8. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elevated non seminomas

9. midline neck swelling moves with protrusion of tongue
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;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

10. What is hungry bone syndrome?
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Retrograde ejaculation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

11. management of gunshot wound
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
If any compressive symptoms eg. dysphagia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

12. What is terrible triad
Patellar tendon tear; difficulty in extension
If patient ambulatory - surgery and pain control; if not nonop mx
S2-S4
MAT; medial meniscus injury; ACL and Tibial colateral ligament

13. suprapubic catheterization
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Klinefelter syndrome; 50 fold increase;
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;
When urethral catherization is unsuccessful

14. lacunar stroke
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound
Pure motor stroke; limited neurological dysfunction
Increased size during the day and valsalva means it is communicated with peritoneal cavity

15. Dupuytren contracture
Amoxicillin-clavulanate
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

16. 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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

17. Can we use beta blocker for pvd?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Study showed no adverse effect; but they are contraindicated for PVD
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

18. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

19. beta hcg and AFP
Carpal tunnel syndrom
Brardycardia - HTN - resp depression
Elevated non seminomas
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

20. How to manage a patient with asystole
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dumping syndrome; small and frequent meals; no simple sugar
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

21. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro

22. scrotal trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Next best step surgery; not ultrasound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

23. What time frame required for bone remodeling
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months
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

24. when scaphoid fx patient needs to be referred to orthopedic
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Fx displace >1mm - nonunion during followup - osteonecrosis
50%; tunneling between rectum or kin

25. swelling and tenderness in anterior part of knee
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
15-40%; self limiting;doesn't require tx
Patellar tendon tear; difficulty in extension
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

26. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Less than 5mm
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely

27. What is most common lung injury after blunt chest trauma?
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
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
L5 to S2
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

28. 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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

29. complication displaced or communited distal radial fx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Carpal tunnel syndrom

30. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Amoxicillin-clavulanate
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

31. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Meniscus injury; medial most common; pain/swelling; popping sensation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Urethral stricture; pelvic of urethral trauma
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

32. varicose veins with ulcer - bleeding and thrombophlebitits
Ispilateral hypoglossal nerve injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

33. common complication of inadequate mx of scaphoid fx
Study showed no adverse effect; but they are contraindicated for PVD
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Nonunion and avascular necrosis; fx can block blood supply;

34. Why varicocele more common in the left side
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4-6 weeks for noncontact sports and longer time for contact sports
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

35. mx of stress fx
Carpal tunnel syndrom
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

36. dumping syndrome after gastrectomy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Urethral stricture; pelvic of urethral trauma
Mammogram

37. stress fx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Compression stocking - weight reduction - leg elevation
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

38. Incidence of AF in CABG patient

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39. varicocele
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

40. cremasteric reflex test?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Twisting force with the foot fixed on the ground seen in football and basketball games;

41. antibiotics of acute cholecystitis
Pure motor stroke; limited neurological dysfunction
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

42. most common complication of acute cholecystitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Unilateral vocal cord paralysis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

43. several knee pain after being tackled in football game
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Abd pain and tenderness; bloody diarrhoea or hematochezia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

44. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Urethral stricture; pelvic of urethral trauma
Seminomas
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

45. How to dx ACL tear?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

46. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

47. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Tendons more likely
CRPS
Malignancy until proven otherwise
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

48. management of nondisplaced scaphoid fx
Tendons more likely
Check ET tube placement if correct needle decompresion
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

49. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
S2-S4

50. painless testicular mass in young male
Malignancy until proven otherwise
Elderly and critically ill patients
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Fx displace >1mm - nonunion during followup - osteonecrosis