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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. clavicle fx
Pure motor stroke; limited neurological dysfunction
Displaced ORIF ; nondisplaced sling immobilization
L5 to S2
S2-S4

2. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
10-12 months
Low anterior resection and radio; add chemo if node positive
Ampicillin sublactum - pipercillin - ceftriaxone and metro

3. management of nondisplaced scaphoid fx
Patellar tendon tear; difficulty in extension
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

4. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Low anterior resection and radio; add chemo if node positive
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

5. characteristics of ureteral stone?
Supraglottic edema; low threshold for intubation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

6. 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;
CRPS
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

7. What is the contraindication of hyperventilation in inc ICP
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Strok and traumatic brain injury
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;

8. differential of ultrasound finding of breast mass
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Even after ochiopexy risk of ochiopexy higher then general population
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

9. surgery for acute cholecystities
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS
Ispilateral hypoglossal nerve injury
24-48 hours of supportive therapy followed by cholecystectomy

10. How to dx ACL tear?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

11. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

12. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Mammogram
Elevated non seminomas
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

13. DD of acute scrotal pain
Cystic scrotal fluid collection between parietal and visceral layers of testis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
When urethral catherization is unsuccessful

14. acute colonic ischemia
Check ET tube placement if correct needle decompresion
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
50%; tunneling between rectum or kin
Abd pain and tenderness; bloody diarrhoea or hematochezia

15. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Patellar tendon tear; difficulty in extension
Check ET tube placement if correct needle decompresion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

16. Patient underwent CABG; postoperatively drowsy. most likely cause?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
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
Meniscus injury; medial most common; pain/swelling; popping sensation

17. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
SAH due to post communicating artery aneurysm;

18. Can we use beta blocker for pvd?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Study showed no adverse effect; but they are contraindicated for PVD
Cystic scrotal fluid collection between parietal and visceral layers of testis

19. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Meniscus injury; medial most common; pain/swelling; popping sensation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Saline and silicone

20. management of gunshot wound
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
4-6 weeks for noncontact sports and longer time for contact sports
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

21. How varicocele causes testicular atrophy
Pure motor stroke; limited neurological dysfunction
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

22. inhalation of hot air - steam - smoke in burn victim
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;
Supraglottic edema; low threshold for intubation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

23. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fx displace >1mm - nonunion during followup - osteonecrosis

24. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Amoxicillin-clavulanate

25. cremasteric reflex test?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
10-12 months
Seminomas

26. recurrent laryngeal nerve injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Klinefelter syndrome; 50 fold increase;
Unilateral vocal cord paralysis
Strok and traumatic brain injury

27. diarrhoea after gastric bypass
Carpal tunnel syndrom
Ispilateral hypoglossal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar
Patellar tendon tear; difficulty in extension

28. xray finding of stress fx after 3-4w
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

29. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
4-6 weeks for noncontact sports and longer time for contact sports

30. popping sensation; rapid onset of knee effusion. athelet
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
ACL injury
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
Patellar tendon tear; difficulty in extension

31. When patient can go back to sports after clavicle fx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
4-6 weeks for noncontact sports and longer time for contact sports
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

32. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

33. How to manage obesity
S2-S4
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Check ET tube placement if correct needle decompresion

34. 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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

35. beta HCG
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elevated non seminomas
Seminomas
Dumping syndrome; small and frequent meals; no simple sugar

36. What is most common lung injury after blunt chest trauma?
24-48 hours of supportive therapy followed by cholecystectomy
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;
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

37. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Compression stocking - weight reduction - leg elevation
CRPS
Seminomas

38. When to stop raloxifene before surgery
Nonunion and avascular necrosis; fx can block blood supply;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

39. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

40. When goiter needs surgery
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Even after ochiopexy risk of ochiopexy higher then general population
If any compressive symptoms eg. dysphagia
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

41. What types of breast implants are available
Tendons more likely
4-6 weeks for noncontact sports and longer time for contact sports
Saline and silicone
Seminomas

42. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Next best step surgery; not ultrasound
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Cystic scrotal fluid collection between parietal and visceral layers of testis

43. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

44. How mcmurray manuver perform
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Pure motor stroke; limited neurological dysfunction
Nonunion and avascular necrosis; fx can block blood supply;

45. SAH due to posterior inferior cerebellar aneurysm
Even after ochiopexy risk of ochiopexy higher then general population
Headache - ataxia - bulbar dysfunction
Next best step surgery; not ultrasound
Patellar tendon tear; difficulty in extension

46. How to perform lachman test
Amoxicillin-clavulanate
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Strok and traumatic brain injury
Meniscus injury; medial most common; pain/swelling; popping sensation

47. first line of management of PVD
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Strok and traumatic brain injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

48. complications of TPN
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Supraglottic edema; low threshold for intubation

49. Dupuytren contracture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Progressive fibrosis of palmar fascia. etiololgy not known;
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

50. diarrhoea 4-5 days after cholecystectomy
Supraglottic edema; low threshold for intubation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Compression stocking - weight reduction - leg elevation