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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 fx when falling on outsretched hand
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
SAH due to post communicating artery aneurysm;
Amoxicillin-clavulanate
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

2. Tx of pulmonary contusion
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%; tunneling between rectum or kin
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Even after ochiopexy risk of ochiopexy higher then general population

3. What is most common lung injury after blunt chest trauma?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

4. acute colonic ischemia
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia

5. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Compression stocking - weight reduction - leg elevation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
10-12 months
Subphrenic abscess or other abdominal abscesses; order US or CT

6. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Meniscus injury; medial most common; pain/swelling; popping sensation
MAT; medial meniscus injury; ACL and Tibial colateral ligament

7. scrotal trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Next best step surgery; not ultrasound
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

8. What time frame required for bone remodeling
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
10-12 months
Tendons more likely

9. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound 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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

10. cremasteric reflex test?
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dumping syndrome; small and frequent meals; no simple sugar
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

11. sudden onset of postoperative hyperglycemia when patient on TPN
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
L5 to S2
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

12. diarrhoea after gastric bypass
Saline and silicone
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dumping syndrome; small and frequent meals; no simple sugar
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

13. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If patient ambulatory - surgery and pain control; if not nonop mx
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

14. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
10-12 months
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

15. Tx of proximal non metastatic rectal ca
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

16. 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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

17. When do we see complications due to hypophosphatemia
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;
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Elderly and critically ill patients

18. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Saline and silicone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

19. What is terrible triad
Retrograde ejaculation
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Ispilateral hypoglossal nerve injury

20. how hyperventilation lowers ICP
Low anterior resection and radio; add chemo if node positive
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

21. Why ruq calcificaion is concerning
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Klinefelter syndrome; 50 fold increase;
Carpal tunnel syndrom

22. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
24-48 hours of supportive therapy followed by cholecystectomy
SAH due to post communicating artery aneurysm;

23. What is hungry bone syndrome?
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
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

24. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Headache - ataxia - bulbar dysfunction
Tendons more likely

25. What is the complications of undescended testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Check ET tube placement if correct needle decompresion
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Even after ochiopexy risk of ochiopexy higher then general population

26. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

27. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Dm neuropathy; stocking glove pattern
Elderly and critically ill patients
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

28. How to confirm dx of compartment 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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

29. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;

30. managment of animal bite in hands
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
24-48 hours of supportive therapy followed by cholecystectomy
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;

31. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Headache - ataxia - bulbar dysfunction
SAH due to post communicating artery aneurysm;

32. DD of acute scrotal pain
Even after ochiopexy risk of ochiopexy higher then general population
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Carpal tunnel syndrom

33. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Compression stocking - weight reduction - leg elevation

34. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. mx of stress fx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

36. conservative Tx of varicose veins
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation
Check ET tube placement if correct needle decompresion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

37. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely
If patient ambulatory - surgery and pain control; if not nonop mx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

38. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Klinefelter syndrome; 50 fold increase;

39. first line of management of PVD
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

40. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Compression stocking - weight reduction - leg elevation

41. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

42. anal sphincter tone
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
S2-S4
Patellar tendon tear; difficulty in extension
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

43. How to manage a patient with asystole
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Low anterior resection and radio; add chemo if node positive
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Dumping syndrome; small and frequent meals; no simple sugar
Less than 5mm
SAH due to post communicating artery aneurysm;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

45. What is hydrocele?
Dm neuropathy; stocking glove pattern
Cystic scrotal fluid collection between parietal and visceral layers of testis
Brardycardia - HTN - resp depression
Urethral stricture; pelvic of urethral trauma

46. aspiration of breast cyst is bloody
Next best step surgery; not ultrasound
Mammogram
If patient ambulatory - surgery and pain control; if not nonop mx
Study showed no adverse effect; but they are contraindicated for PVD

47. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
ACL injury
Mammogram

48. How to evaluate painless testicular swelling suspicious for cancer
S2-S4
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

49. differential of ultrasound finding of breast mass
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;
Next best step surgery; not ultrasound
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

50. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
CRPS
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;
Retrograde ejaculation