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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. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Tendons more likely
Subphrenic abscess or other abdominal abscesses; order US or CT
Amoxicillin-clavulanate

2. SOB - confusion - petechial rash after trauma - fracture
Seminomas
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

3. management of hip fracture
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
10-12 months
Saline and silicone
If patient ambulatory - surgery and pain control; if not nonop mx

4. common complication of inadequate mx of scaphoid fx
Amoxicillin-clavulanate
Nonunion and avascular necrosis; fx can block blood supply;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

5. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Carpal tunnel syndrom
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
SAH due to post communicating artery aneurysm;
Malignancy until proven otherwise

6. 27 yo with scrotal mass; warm tender testes feel like bag of worms
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
ACL injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

7. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
When urethral catherization is unsuccessful
Strok and traumatic brain injury
CRPS

8. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Retrograde ejaculation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

9. How to manage a patient with asystole
Elevated non seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Patellar tendon tear; difficulty in extension

10. when scaphoid fx patient needs to be referred to orthopedic
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Fx displace >1mm - nonunion during followup - osteonecrosis
Supraglottic edema; low threshold for intubation
Less than 5mm

11. xray finding of stress fx after 3-4w
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Carpal tunnel syndrom
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

13. differential of ultrasound finding of breast mass
Displaced ORIF ; nondisplaced sling immobilization
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
Tendons more likely
Malignancy until proven otherwise

14. ipsilateral deviation of tongue upon protrusion
Low anterior resection and radio; add chemo if node positive
Ispilateral hypoglossal nerve injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

15. When goiter needs surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If any compressive symptoms eg. dysphagia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
10-12 months

16. dorsiflexion and planter flexion
Brardycardia - HTN - resp depression
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2

17. complications of TPN
If patient ambulatory - surgery and pain control; if not nonop mx
Carpal tunnel syndrom
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

18. How to manage obesity
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS

19. How to perform lachman test
Seminomas
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Meniscus injury; medial most common; pain/swelling; popping sensation

20. Dupuytren contracture
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
Ispilateral hypoglossal nerve injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression

21. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elevated non seminomas
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

22. Incidence of AF in CABG patient

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23. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Low anterior resection and radio; add chemo if node positive
Dm neuropathy; stocking glove pattern
Urethral stricture; pelvic of urethral trauma

24. Indication for bariatric surgery in obese patients
Less than 5mm
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Strok and traumatic brain injury

25. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
S2-S4
10-12 months
Check ET tube placement if correct needle decompresion

26. How to dx ACL tear?
Nonunion and avascular necrosis; fx can block blood supply;
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
4-6 weeks for noncontact sports and longer time for contact sports
Strok and traumatic brain injury

27. 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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;

28. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

29. Tx of pulmonary contusion
Displaced ORIF ; nondisplaced sling immobilization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mammogram
Tendons more likely

30. Why varicocele more common in the left side
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
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;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

31. transrectal prostate biopsy
Mammogram
Retrograde ejaculation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

32. cremasteric reflex test?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Twisting force with the foot fixed on the ground seen in football and basketball games;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

33. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Unilateral vocal cord paralysis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

34. 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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx

35. types of hip fracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

36. conservative Tx of varicose veins
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Compression stocking - weight reduction - leg elevation

37. surgery for acute cholecystities
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
24-48 hours of supportive therapy followed by cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Less than 5mm

38. severe pain in leg after MVC
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

39. managment of animal bite in hands
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

40. inhalation of hot air - steam - smoke in burn victim
ACL injury
Supraglottic edema; low threshold for intubation
10-12 months
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

41. first step for evaluation of testicular swelling
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Sphincter sparing surgery (local resection) - abdomnio perineal resection

42. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Meniscus injury; medial most common; pain/swelling; popping sensation

43. What percent of anal abscess deveolop fisutula
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
Tendons more likely
50%; tunneling between rectum or kin
Sphincter sparing surgery (local resection) - abdomnio perineal resection

44. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

45. menisci injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Carpal tunnel syndrom
Twisting force with the foot fixed on the ground seen in football and basketball games;

46. What time frame required for bone remodeling
Progressive fibrosis of palmar fascia. etiololgy not known;
10-12 months
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Displaced ORIF ; nondisplaced sling immobilization

47. suprapubic catheterization
Displaced ORIF ; nondisplaced sling immobilization
Abd pain and tenderness; bloody diarrhoea or hematochezia
When urethral catherization is unsuccessful
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

48. Why ruq calcificaion is concerning
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

49. Valgus and Varus tests
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. Why right varicocele is more concerning?

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