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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. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

2. most common fx when falling on outsretched hand
CRPS
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dumping syndrome; small and frequent meals; no simple sugar
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

3. Patient underwent CABG; postoperatively drowsy. most likely cause?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

4. how hyperventilation lowers ICP
Unilateral vocal cord paralysis
10-12 months
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

5. mx of stress fx
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

6. acute colonic ischemia
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Increased size during the day and valsalva means it is communicated with peritoneal cavity

7. lacerated wound in palmer surface of hand. what structure is injured?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

8. aspiration of breast cyst is bloody
Urethral stricture; pelvic of urethral trauma
Mammogram
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

9. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Saline and silicone

10. acalculus cholecystitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Elderly and critically ill patients
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

11. cat/dog bites
ACL injury
Nonunion and avascular necrosis; fx can block blood supply;
Amoxicillin-clavulanate
Sphincter sparing surgery (local resection) - abdomnio perineal resection

12. How to evaluate painless testicular swelling suspicious for cancer
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
24-48 hours of supportive therapy followed by cholecystectomy

13. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months
Mammogram

14. What are the common injuries from lightning?
Headache - ataxia - bulbar dysfunction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

15. What is the complications of undescended testis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Even after ochiopexy risk of ochiopexy higher then general population
Amoxicillin-clavulanate

16. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Cystic scrotal fluid collection between parietal and visceral layers of testis
Check ET tube placement if correct needle decompresion
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

17. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
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;
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

18. management of stone 8-10mm
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

19. dumping syndrome after gastrectomy
Headache - ataxia - bulbar dysfunction
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;

20. How to confirm achiles tendon rupture
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

21. popping sensation; rapid onset of knee effusion. athelet
4-6 weeks for noncontact sports and longer time for contact sports
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
ACL injury

22. When patient can go back to sports after clavicle fx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
When urethral catherization is unsuccessful
24-48 hours of supportive therapy followed by cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports

23. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
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

24. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

25. dorsiflexion and planter flexion
Elderly and critically ill patients
CRPS
L5 to S2
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

26. pregnant patient with asymptomatic gall stones
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

27. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
S2-S4
Dm neuropathy; stocking glove pattern

28. characteristics of ureteral stone?
Tendons more likely
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

29. surgery for acute cholecystities
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;
24-48 hours of supportive therapy followed by cholecystectomy

30. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

31. 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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
S2-S4
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

32. How to dx ACL tear?
Dumping syndrome; small and frequent meals; no simple sugar
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

33. severe pain in leg after MVC
Ispilateral hypoglossal nerve 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;
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
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

34. When do we see complications due to hypophosphatemia
S2-S4
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

35. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Headache - ataxia - bulbar dysfunction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

36. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Meniscus injury; medial most common; pain/swelling; popping sensation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

37. antibiotics of acute cholecystitis
Pure motor stroke; limited neurological dysfunction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dm neuropathy; stocking glove pattern
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

38. beta HCG
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Subphrenic abscess or other abdominal abscesses; order US or CT
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Seminomas

39. Why right varicocele is more concerning?

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40. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

41. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Fx displace >1mm - nonunion during followup - osteonecrosis
Low anterior resection and radio; add chemo if node positive
Urethral stricture; pelvic of urethral trauma

42. recurrent laryngeal nerve injury
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
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
Unilateral vocal cord paralysis

43. management of gunshot wound
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Patellar tendon tear; difficulty in extension
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

44. Why varicocele more common in the left side
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

45. lacunar stroke
CRPS
Amoxicillin-clavulanate
Pure motor stroke; limited neurological dysfunction
Progressive fibrosis of palmar fascia. etiololgy not known;

46. What is the strongest risk factor for male breast cancer
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Klinefelter syndrome; 50 fold increase;
Check ET tube placement if correct needle decompresion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

47. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dm neuropathy; stocking glove pattern

48. What time frame required for bone remodeling
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
10-12 months

49. Valgus and Varus tests
Check ET tube placement if correct needle decompresion
Ampicillin sublactum - pipercillin - ceftriaxone and metro
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Even after ochiopexy risk of ochiopexy higher then general population

50. how ABI help dx of PVD
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
Seminomas
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia