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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. What are the common injuries from lightning?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

2. 3 mo with groin bulge; bulge appears when child cries
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Klinefelter syndrome; 50 fold increase;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

3. suprapubic catheterization
Meniscus injury; medial most common; pain/swelling; popping sensation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elderly and critically ill patients
When urethral catherization is unsuccessful

4. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Amoxicillin-clavulanate
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

5. most frequent complication of TURP
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Retrograde ejaculation
When urethral catherization is unsuccessful

6. transrectal prostate biopsy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Twisting force with the foot fixed on the ground seen in football and basketball games;

7. What is hungry bone syndrome?
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
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;
Low anterior resection and radio; add chemo if node positive

8. 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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

9. beta hcg and AFP
Increased size during the day and valsalva means it is communicated with peritoneal cavity
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Elevated non seminomas

10. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Study showed no adverse effect; but they are contraindicated for PVD
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

11. dumping syndrome after gastrectomy
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If any compressive symptoms eg. dysphagia

12. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If any compressive symptoms eg. dysphagia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

13. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
SAH due to post communicating artery aneurysm;
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;

14. when scaphoid fx patient needs to be referred to orthopedic
Tendons more likely
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months

15. beta HCG
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Meniscus injury; medial most common; pain/swelling; popping sensation
Seminomas

16. What is cushing's triad
24-48 hours of supportive therapy followed by cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Brardycardia - HTN - resp depression

17. What is the strongest risk factor for male breast cancer
Next best step surgery; not ultrasound
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;
Mammogram
Klinefelter syndrome; 50 fold increase;

18. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Ispilateral hypoglossal nerve injury

19. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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;
Check ET tube placement if correct needle decompresion
Headache - ataxia - bulbar dysfunction
Strok and traumatic brain injury

20. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Ispilateral hypoglossal nerve injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

21. surgery for acute cholecystities
Check ET tube placement if correct needle decompresion
24-48 hours of supportive therapy followed by cholecystectomy
Elevated non seminomas
Dm neuropathy; stocking glove pattern

22. What is the complications of undescended testis
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Even after ochiopexy risk of ochiopexy higher then general population
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

23. What is most common lung injury after blunt chest trauma?
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Progressive fibrosis of palmar fascia. etiololgy not known;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

24. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
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
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
24-48 hours of supportive therapy followed by cholecystectomy
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
Check ET tube placement if correct needle decompresion

26. how ABI help dx of PVD
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

27. stress fx
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

28. how hyperventilation lowers ICP
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Study showed no adverse effect; but they are contraindicated for PVD

29. most common complication of acute cholecystitis
L5 to S2
Dm neuropathy; stocking glove pattern
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

30. Valgus and Varus tests
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months

31. What time frame required for bone remodeling
10-12 months
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
S2-S4
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

32. Why varicocele more common in the left side
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
Strok and traumatic brain injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

33. When to do surgery in undesceneded testis?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Check ET tube placement if correct needle decompresion
Increased size during the day and valsalva means it is communicated with peritoneal cavity

34. Most common of sudden death due to steering wheel injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If patient ambulatory - surgery and pain control; if not nonop mx

35. differential of ultrasound finding of breast mass
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
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
Displaced ORIF ; nondisplaced sling immobilization
Meniscus injury; medial most common; pain/swelling; popping sensation

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Patellar tendon tear; difficulty in extension
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If any compressive symptoms eg. dysphagia
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

37. Indication for bariatric surgery in obese patients
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;
50%; tunneling between rectum or kin
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

38. 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)
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.
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

39. recurrent laryngeal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Unilateral vocal cord paralysis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

40. midline neck swelling moves with protrusion of tongue
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
ACL injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament

41. What is prehn sign?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
15-40%; self limiting;doesn't require tx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If any compressive symptoms eg. dysphagia

42. Why initial xrays are negative in scaphoid fx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Dumping syndrome; small and frequent meals; no simple sugar
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

43. 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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Amoxicillin-clavulanate
4-6 weeks for noncontact sports and longer time for contact sports

44. How to dx ACL tear?
Dumping syndrome; small and frequent meals; no simple sugar
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

45. painless testicular mass in young male
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
Malignancy until proven otherwise
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
L5 to S2

46. types of hip fracture
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Elevated non seminomas

47. 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;
Saline and silicone
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction

48. what size of ureteral stone for non op mx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Less than 5mm
CRPS

49. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Mammogram

50. Why ruq calcificaion is concerning
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;