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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. antibiotics of acute 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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
15-40%; self limiting;doesn't require tx
Ampicillin sublactum - pipercillin - ceftriaxone and metro

2. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

3. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Subphrenic abscess or other abdominal abscesses; order US or CT

4. first step for evaluation of testicular swelling
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

5. common complication of inadequate mx of scaphoid fx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Nonunion and avascular necrosis; fx can block blood supply;
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
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

6. indication of ursodeoxycholic acid
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
Ispilateral hypoglossal nerve injury
Retrograde ejaculation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

7. ct scan; cystic lesion in head of pancreas; next step
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

8. complication displaced or communited distal radial fx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Carpal tunnel syndrom
Even after ochiopexy risk of ochiopexy higher then general population

9. SAH due to posterior inferior cerebellar aneurysm
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Headache - ataxia - bulbar dysfunction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

10. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Headache - ataxia - bulbar dysfunction

11. transrectal prostate biopsy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
15-40%; self limiting;doesn't require tx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

12. aspiration of breast cyst is nonbloody
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
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

13. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Supraglottic edema; low threshold for intubation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

14. How to dx ACL tear?
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Saline and silicone
Pure motor stroke; limited neurological dysfunction

15. DD of acute scrotal pain
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevated non seminomas
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

16. Dupuytren contracture
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

17. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

18. Valgus and Varus tests
Amoxicillin-clavulanate
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
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

19. 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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Strok and traumatic brain injury

20. cremasteric reflex
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Low anterior resection and radio; add chemo if node positive

21. mx of stress fx
If patient ambulatory - surgery and pain control; if not nonop mx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Ispilateral hypoglossal nerve injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

22. 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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

23. dorsiflexion and planter flexion
Carpal tunnel syndrom
Dumping syndrome; small and frequent meals; no simple sugar
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
L5 to S2

24. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

25. How to manage a patient with asystole
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

26. sudden onset of postoperative hyperglycemia when patient on TPN
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

27. inhalation of hot air - steam - smoke in burn victim
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Supraglottic edema; low threshold for intubation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

28. Tx of pulmonary contusion
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Carpal tunnel syndrom

29. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

30. surgery for acute cholecystities
Compression stocking - weight reduction - leg elevation
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;
ACL injury
24-48 hours of supportive therapy followed by cholecystectomy

31. What is cushing's triad
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Brardycardia - HTN - resp depression
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

32. What types of breast implants are available
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Saline and silicone
10-12 months
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

33. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Retrograde ejaculation
Mammogram
CRPS

34. first line of management of PVD
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
L5 to S2

35. what size of ureteral stone for non op mx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
4-6 weeks for noncontact sports and longer time for contact sports
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Less than 5mm

36. How to evaluate painless testicular swelling suspicious for cancer
50%; tunneling between rectum or kin
Less than 5mm
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Progressive fibrosis of palmar fascia. etiololgy not known;

37. 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
Malignancy until proven otherwise
Elevated non seminomas
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

38. management of stone 8-10mm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

39. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
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;
SAH due to post communicating artery aneurysm;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

40. suprapubic catheterization
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
When urethral catherization is unsuccessful
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

41. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Subphrenic abscess or other abdominal abscesses; order US or CT
Headache - ataxia - bulbar dysfunction
Patellar tendon tear; difficulty in extension

42. varicocele
When urethral catherization is unsuccessful
Pure motor stroke; limited neurological dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
15-40%; self limiting;doesn't require tx

43. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Patellar tendon tear; difficulty in extension

44. contraindication of urethral catheterization
S2-S4
Mammogram
Urethral stricture; pelvic of urethral trauma
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

45. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Cystic scrotal fluid collection between parietal and visceral layers of testis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Low anterior resection and radio; add chemo if node positive
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

46. How varicocele causes testicular atrophy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fx displace >1mm - nonunion during followup - osteonecrosis
If patient ambulatory - surgery and pain control; if not nonop mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

47. types of hip fracture
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

48. characteristics of ureteral stone?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

49. how hyperventilation lowers ICP
Elderly and critically ill patients
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

50. management of nondisplaced scaphoid fx
Malignancy until proven otherwise
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Epi and chest compressio for prolong period of time; atropine is given after epi;