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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. management of gunshot wound
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Retrograde ejaculation
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
15-40%; self limiting;doesn't require tx

2. beta HCG
Seminomas
Progressive fibrosis of palmar fascia. etiololgy not known;
Tendons more likely
Study showed no adverse effect; but they are contraindicated for PVD

3. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Increased size during the day and valsalva means it is communicated with peritoneal cavity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dm neuropathy; stocking glove pattern

4. What types of breast implants are available
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Saline and silicone
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

5. What time frame required for bone remodeling
10-12 months
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
When urethral catherization is unsuccessful
Displaced ORIF ; nondisplaced sling immobilization

6. swelling and tenderness in anterior part of knee
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Patellar tendon tear; difficulty in extension

7. What is the contraindication of hyperventilation in inc ICP
When urethral catherization is unsuccessful
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Epi and chest compressio for prolong period of time; atropine is given after epi;
Strok and traumatic brain injury

8. How to dx ACL tear?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Abd pain and tenderness; bloody diarrhoea or hematochezia

9. beta hcg and AFP
Elevated non seminomas
4-6 weeks for noncontact sports and longer time for contact sports
Epi and chest compressio for prolong period of time; atropine is given after epi;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

10. Why right varicocele is more concerning?

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11. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Urethral stricture; pelvic of urethral trauma
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

12. sudden onset of postoperative hyperglycemia when patient on TPN
Even after ochiopexy risk of ochiopexy higher then general population
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Seminomas

13. clavicle fx
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;
15-40%; self limiting;doesn't require tx
Pure motor stroke; limited neurological dysfunction
Displaced ORIF ; nondisplaced sling immobilization

14. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Patellar tendon tear; difficulty in extension
Mammogram

15. dumping syndrome after gastrectomy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
L5 to S2
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Even after ochiopexy risk of ochiopexy higher then general population

16. when patient with severe lung disease have C02 retention
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

17. When patient can go back to sports after clavicle fx
Meniscus injury; medial most common; pain/swelling; popping sensation
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
4-6 weeks for noncontact sports and longer time for contact sports

18. How to differentiate ACL and meniscus 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
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

19. Indication for bariatric surgery in obese patients
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Compression stocking - weight reduction - leg elevation

20. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

21. How to manage a patient with asystole
Mammogram
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dm neuropathy; stocking glove pattern
Epi and chest compressio for prolong period of time; atropine is given after epi;

22. Valgus and Varus tests
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
15-40%; self limiting;doesn't require tx
Next best step surgery; not ultrasound

23. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Strok and traumatic brain injury
L5 to S2
Abd pain and tenderness; bloody diarrhoea or hematochezia

24. Can we use beta blocker for pvd?
Epi and chest compressio for prolong period of time; atropine is given after epi;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Malignancy until proven otherwise
Study showed no adverse effect; but they are contraindicated for PVD

25. When goiter needs surgery
If any compressive symptoms eg. dysphagia
CRPS
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

26. xray finding of stress fx after 3-4w
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
50%; tunneling between rectum or kin
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

27. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mammogram
Pure motor stroke; limited neurological dysfunction

28. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

29. what size of ureteral stone for non op mx
Less than 5mm
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

30. perioral numbness after parathyroidectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
L5 to S2
Brardycardia - HTN - resp depression

31. SAH due to posterior inferior cerebellar aneurysm
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Headache - ataxia - bulbar dysfunction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

32. Tx of pulmonary contusion
Check ET tube placement if correct needle decompresion
ACL injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Progressive fibrosis of palmar fascia. etiololgy not known;

33. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

34. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Abd pain and tenderness; bloody diarrhoea or hematochezia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

35. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Even after ochiopexy risk of ochiopexy higher then general population
Study showed no adverse effect; but they are contraindicated for PVD

36. antibiotics of acute cholecystitis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Compression stocking - weight reduction - leg elevation

37. cremasteric reflex
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Nonunion and avascular necrosis; fx can block blood supply;

38. What is the strongest risk factor for male breast cancer
Headache - ataxia - bulbar dysfunction
Klinefelter syndrome; 50 fold increase;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
15-40%; self limiting;doesn't require tx

39. most common fx when falling on outsretched hand
CRPS
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

40. first step for evaluation of testicular swelling
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

41. inhalation of hot air - steam - smoke in burn victim
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
Supraglottic edema; low threshold for intubation
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

42. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elderly and critically ill patients

43. management of stone 8-10mm
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Saline and silicone

44. aspiration of breast cyst is bloody
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Unilateral vocal cord paralysis
Check ET tube placement if correct needle decompresion
Mammogram

45. recurrent laryngeal nerve injury
Low anterior resection and radio; add chemo if node positive
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Unilateral vocal cord paralysis

46. Tx of proximal non metastatic rectal ca
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
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive

47. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Subphrenic abscess or other abdominal abscesses; order US or CT
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

48. How to perform lachman test
CRPS
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Retrograde ejaculation

49. How to differentiate communicative and non-communicative hydrocele
Study showed no adverse effect; but they are contraindicated for PVD
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Saline and silicone
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

50. How to manage obesity
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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