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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 is the strongest risk factor for male breast cancer
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
When urethral catherization is unsuccessful
Klinefelter syndrome; 50 fold increase;
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

2. swelling and tenderness in anterior part of knee
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension

3. Patient underwent CABG; postoperatively drowsy. most likely cause?
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Strok and traumatic brain injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

4. pregnant patient with asymptomatic gall stones
Subphrenic abscess or other abdominal abscesses; order US or CT
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

5. What percent of anal abscess deveolop fisutula
S2-S4
50%; tunneling between rectum or kin
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

6. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
ACL injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

7. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Study showed no adverse effect; but they are contraindicated for PVD
Subphrenic abscess or other abdominal abscesses; order US or CT
Saline and silicone
Malignancy until proven otherwise

8. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Progressive fibrosis of palmar fascia. etiololgy not known;
Unilateral vocal cord paralysis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

9. Most common of sudden death due to steering wheel injury
4-6 weeks for noncontact sports and longer time for contact sports
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

10. acute colonic ischemia
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If any compressive symptoms eg. dysphagia

11. Why right varicocele is more concerning?

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12. 3 mo with groin bulge; bulge appears when child cries
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pure motor stroke; limited neurological dysfunction
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

13. Dupuytren contracture
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Progressive fibrosis of palmar fascia. etiololgy not known;
If any compressive symptoms eg. dysphagia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

14. painless testicular mass in young male
Compression stocking - weight reduction - leg elevation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Malignancy until proven otherwise
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

15. management of hip fracture
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
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 patient ambulatory - surgery and pain control; if not nonop mx

16. When do we see complications due to hypophosphatemia
Pure motor stroke; limited neurological dysfunction
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;
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

17. lacunar stroke
Compression stocking - weight reduction - leg elevation
Elevated non seminomas
Even after ochiopexy risk of ochiopexy higher then general population
Pure motor stroke; limited neurological dysfunction

18. management of nondisplaced 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
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

19. transrectal prostate biopsy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Study showed no adverse effect; but they are contraindicated for PVD

20. How to dx ACL tear?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Unilateral vocal cord paralysis
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
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

21. aspiration of breast cyst is bloody
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Mammogram
Headache - ataxia - bulbar dysfunction
Epi and chest compressio for prolong period of time; atropine is given after epi;

22. differential of ultrasound finding of breast mass
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
Fx displace >1mm - nonunion during followup - osteonecrosis
4-6 weeks for noncontact sports and longer time for contact sports
Unilateral vocal cord paralysis

23. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Low anterior resection and radio; add chemo if node positive
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

24. How to differentiate communicative and non-communicative hydrocele
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If any compressive symptoms eg. dysphagia

25. What is the complications of undescended testis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Even after ochiopexy risk of ochiopexy higher then general population
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

26. prostate enlarged - nontender - no nodularity - elevated PSA
Saline and silicone
Check ET tube placement if correct needle decompresion
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

27. 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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

28. popping sensation; rapid onset of knee effusion. athelet
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

29. ipsilateral deviation of tongue upon protrusion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Ispilateral hypoglossal nerve injury

30. How to confirm achiles tendon rupture
Progressive fibrosis of palmar fascia. etiololgy not known;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Supraglottic edema; low threshold for intubation

31. cat/dog bites
SAH due to post communicating artery aneurysm;
Amoxicillin-clavulanate
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Study showed no adverse effect; but they are contraindicated for PVD

32. most frequent complication of TURP
Nonunion and avascular necrosis; fx can block blood supply;
Retrograde ejaculation
S2-S4
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

33. anal sphincter tone
S2-S4
Next best step surgery; not ultrasound
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Meniscus injury; medial most common; pain/swelling; popping sensation

34. most common fx when falling on outsretched hand
Low anterior resection and radio; add chemo if node positive
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

35. mx of stress fx
Progressive fibrosis of palmar fascia. etiololgy not known;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

36. ct scan; cystic lesion in head of pancreas; next step
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
ACL injury
Brardycardia - HTN - resp depression
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

37. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elderly and critically ill patients
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

38. diarrhoea after gastric bypass
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar
Abd pain and tenderness; bloody diarrhoea or hematochezia

39. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Subphrenic abscess or other abdominal abscesses; order US or CT
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

40. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Saline and silicone

41. 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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dm neuropathy; stocking glove pattern
SAH due to post communicating artery aneurysm;

42. Complications of breast impant
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
ACL injury

43. several knee pain after being tackled in football game
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

44. characteristics of ureteral stone?
Brardycardia - HTN - resp depression
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
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;

45. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
15-40%; self limiting;doesn't require tx
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;
Elevated non seminomas

46. Indication for bariatric surgery in obese patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal 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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

47. dorsiflexion and planter flexion
L5 to S2
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
Strok and traumatic brain injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

48. management of gunshot wound
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

49. How to perform lachman test
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Ispilateral hypoglossal nerve injury

50. when scaphoid fx patient needs to be referred to orthopedic
Headache - ataxia - bulbar dysfunction
Fx displace >1mm - nonunion during followup - osteonecrosis
Seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection