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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. acalculus cholecystitis
Elderly and critically ill patients
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

2. What types of breast implants are available
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT
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;
Saline and silicone

3. managment of animal bite in hands
Headache - ataxia - bulbar dysfunction
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;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

4. types of hip fracture
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Klinefelter syndrome; 50 fold increase;
Seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

5. Why right varicocele is more concerning?

6. What is the strongest risk factor for male breast cancer
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Klinefelter syndrome; 50 fold increase;
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
Progressive fibrosis of palmar fascia. etiololgy not known;

7. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Displaced ORIF ; nondisplaced sling immobilization
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

8. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If any compressive symptoms eg. dysphagia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

9. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Dm neuropathy; stocking glove pattern
Klinefelter syndrome; 50 fold increase;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

10. inhalation of hot air - steam - smoke in burn victim
Strok and traumatic brain injury
Supraglottic edema; low threshold for intubation
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
Next best step surgery; not ultrasound

11. transrectal prostate biopsy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Fx displace >1mm - nonunion during followup - osteonecrosis

12. lacunar stroke
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Pure motor stroke; limited neurological dysfunction
Tendons more likely
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

13. popping sensation; rapid onset of knee effusion. athelet
SAH due to post communicating artery aneurysm;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Amoxicillin-clavulanate
ACL injury

14. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Strok and traumatic brain injury
Supraglottic edema; low threshold for intubation
Subphrenic abscess or other abdominal abscesses; order US or CT

15. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
L5 to S2

16. Most common of sudden death due to steering wheel injury
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
S2-S4
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Mammogram

17. What are the common injuries from lightning?
Subphrenic abscess or other abdominal abscesses; order US or CT
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

18. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

19. How mcmurray manuver perform
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

20. What is hungry bone syndrome?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

21. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Nonunion and avascular necrosis; fx can block blood supply;
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

22. perioral numbness after parathyroidectomy
Displaced ORIF ; nondisplaced sling immobilization
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 size during the day and valsalva means it is communicated with peritoneal cavity
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

23. management of stone 8-10mm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

24. tx distal rectal ca
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Carpal tunnel syndrom
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

25. differential of ultrasound finding of breast mass
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

26. severe pain in leg after MVC
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
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
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

27. What is hydrocele?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
4-6 weeks for noncontact sports and longer time for contact sports
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Cystic scrotal fluid collection between parietal and visceral layers of testis

28. How to perform lachman test
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

29. SOB - confusion - petechial rash after trauma - fracture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Ampicillin sublactum - pipercillin - ceftriaxone and metro

30. cat/dog bites
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Fx displace >1mm - nonunion during followup - osteonecrosis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Amoxicillin-clavulanate

31. What is prehn sign?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

32. most common fx when falling on outsretched hand
Meniscus injury; medial most common; pain/swelling; popping sensation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Compression stocking - weight reduction - leg elevation

33. 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
If any compressive symptoms eg. dysphagia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
50%; tunneling between rectum or kin

34. ct scan; cystic lesion in head of pancreas; next step
Retrograde ejaculation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ispilateral hypoglossal nerve injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

35. When patient can go back to sports after clavicle fx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Subphrenic abscess or other abdominal abscesses; order US or CT

36. ipsilateral deviation of tongue upon protrusion
Cystic scrotal fluid collection between parietal and visceral layers of testis
Compression stocking - weight reduction - leg elevation
Ispilateral hypoglossal nerve injury
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. anal sphincter tone
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
S2-S4

38. How to differentiate communicative and non-communicative hydrocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Patellar tendon tear; difficulty in extension
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

39. How to dx ACL tear?
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;
Dumping syndrome; small and frequent meals; no simple sugar
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

40. beta hcg and AFP
Elevated non seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

41. cremasteric reflex test?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cystic scrotal fluid collection between parietal and visceral layers of testis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

42. diarrhoea after gastric bypass
Headache - ataxia - bulbar dysfunction
Ispilateral hypoglossal nerve injury
Retrograde ejaculation
Dumping syndrome; small and frequent meals; no simple sugar

43. complication displaced or communited distal radial fx
CRPS
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Pure motor stroke; limited neurological dysfunction
Carpal tunnel syndrom

44. dumping syndrome after gastrectomy
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Low anterior resection and radio; add chemo if node positive

45. several knee pain after being tackled in football game
Saline and silicone
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Tendons more likely

46. When to do surgery in undesceneded testis?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Nonunion and avascular necrosis; fx can block blood supply;

47. what size of ureteral stone for non op mx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ispilateral hypoglossal nerve injury
Fx displace >1mm - nonunion during followup - osteonecrosis
Less than 5mm

48. lacerated wound in palmer surface of hand. what structure is injured?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Meniscus injury; medial most common; pain/swelling; popping sensation

49. mx of stress fx
Retrograde ejaculation
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

50. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Cystic scrotal fluid collection between parietal and visceral layers of testis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele