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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 complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If patient ambulatory - surgery and pain control; if not nonop mx
Displaced ORIF ; nondisplaced sling immobilization
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. How mcmurray manuver perform
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

3. aspiration of breast cyst is bloody
Mammogram
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
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;
Less than 5mm

4. indication of ursodeoxycholic acid
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension
Mammogram
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

5. Why initial xrays are negative in scaphoid fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

6. How to differentiate ACL and meniscus injury
Compression stocking - weight reduction - leg elevation
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Sphincter sparing surgery (local resection) - abdomnio perineal resection

7. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Amoxicillin-clavulanate
Urethral stricture; pelvic of urethral trauma
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

8. 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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Amoxicillin-clavulanate

9. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abd pain and tenderness; bloody diarrhoea or hematochezia

10. When goiter needs surgery
Cystic scrotal fluid collection between parietal and visceral layers of testis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Subphrenic abscess or other abdominal abscesses; order US or CT
If any compressive symptoms eg. dysphagia

11. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
50%; tunneling between rectum or kin
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

12. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Malignancy until proven otherwise
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Subphrenic abscess or other abdominal abscesses; order US or CT

13. How to manage obesity
SAH due to post communicating artery aneurysm;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4-6 weeks for noncontact sports and longer time for contact sports
Cystic scrotal fluid collection between parietal and visceral layers of testis

14. When to stop raloxifene before surgery
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

15. differential of ultrasound finding of breast mass
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

16. acalculus cholecystitis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pure motor stroke; limited neurological dysfunction
Elderly and critically ill patients
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

17. How to confirm dx of compartment syndrom
Tendons more likely
Check ET tube placement if correct needle decompresion
Twisting force with the foot fixed on the ground seen in football and basketball games;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

18. Tx of proximal non metastatic rectal ca
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Low anterior resection and radio; add chemo if node positive
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

19. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
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;
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
Unilateral vocal cord paralysis

20. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
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
Supraglottic edema; low threshold for intubation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

21. anal sphincter tone
S2-S4
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Subphrenic abscess or other abdominal abscesses; order US or CT
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

22. When to do surgery in undesceneded testis?
Amoxicillin-clavulanate
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Meniscus injury; medial most common; pain/swelling; popping sensation

23. 3 mo with groin bulge; bulge appears when child cries
Compression stocking - weight reduction - leg elevation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
CRPS

24. Why right varicocele is more concerning?

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25. most common fx when falling on outsretched hand
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

26. pregnant patient with asymptomatic gall stones
Even after ochiopexy risk of ochiopexy higher then general population
Patellar tendon tear; difficulty in extension
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
MAT; medial meniscus injury; ACL and Tibial colateral ligament

27. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

28. aspiration of breast cyst is nonbloody
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Ispilateral hypoglossal nerve injury

29. How to confirm achiles tendon rupture
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
Less than 5mm
Patellar tendon tear; difficulty in extension
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

30. What is prehn sign?
4-6 weeks for noncontact sports and longer time for contact sports
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

31. perioral numbness after parathyroidectomy
Compression stocking - weight reduction - leg elevation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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 any compressive symptoms eg. dysphagia

32. transrectal prostate biopsy
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Tendons more likely
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

33. most frequent complication of TURP
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Urethral stricture; pelvic of urethral trauma
Retrograde ejaculation

34. ct scan; cystic lesion in head of pancreas; next step
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

35. tx distal rectal ca
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sphincter sparing surgery (local resection) - abdomnio perineal resection

36. What is hydrocele?
50%; tunneling between rectum or kin
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

37. What is the strongest risk factor for male breast cancer
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram
Klinefelter syndrome; 50 fold increase;
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

38. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ampicillin sublactum - pipercillin - ceftriaxone and metro

39. surgery for acute cholecystities
SAH due to post communicating artery aneurysm;
24-48 hours of supportive therapy followed by cholecystectomy
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 could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

40. Why ruq calcificaion is concerning
Malignancy until proven otherwise
Amoxicillin-clavulanate
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

41. cremasteric reflex test?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

42. diarrhoea 4-5 days after cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
L5 to S2
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;

43. How varicocele causes testicular atrophy
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cystic scrotal fluid collection between parietal and visceral layers of testis

44. midline neck swelling moves with protrusion of tongue
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Twisting force with the foot fixed on the ground seen in football and basketball games;

45. beta hcg and AFP
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
10-12 months
Elevated non seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;

46. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

47. beta HCG
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Seminomas
24-48 hours of supportive therapy followed by cholecystectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

48. SOB - confusion - petechial rash after trauma - fracture
Brardycardia - HTN - resp depression
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Strok and traumatic brain injury

49. management of gunshot wound
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Saline and silicone
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

50. acute colonic ischemia
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If patient ambulatory - surgery and pain control; if not nonop mx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Seminomas