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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. How to manage a patient with asystole
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

2. How to perform lachman test
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Saline and silicone
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;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

3. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

4. Why initial xrays are negative in 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
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;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Twisting force with the foot fixed on the ground seen in football and basketball games;

5. Why right varicocele is more concerning?

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6. characteristics of ureteral stone?
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

7. What time frame required for bone remodeling
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
10-12 months
L5 to S2

8. Tx of pulmonary contusion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Low anterior resection and radio; add chemo if node positive
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

9. managment of animal bite in hands
Next best step surgery; not ultrasound
CRPS
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

10. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Displaced ORIF ; nondisplaced sling immobilization
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;

11. 3 mo with groin bulge; bulge appears when child cries
When urethral catherization is unsuccessful
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. lacunar stroke
Check ET tube placement if correct needle decompresion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pure motor stroke; limited neurological dysfunction

13. acalculus cholecystitis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

14. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Low anterior resection and radio; add chemo if node positive
Ampicillin sublactum - pipercillin - ceftriaxone and metro

15. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Patellar tendon tear; difficulty in extension
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

16. How to differentiate ACL and meniscus injury
Tendons more likely
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Unilateral vocal cord paralysis

17. painless testicular mass in young male
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
Malignancy until proven otherwise
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

18. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Headache - ataxia - bulbar dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

19. most frequent complication of TURP
Study showed no adverse effect; but they are contraindicated for PVD
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elderly and critically ill patients
Retrograde ejaculation

20. common complication of inadequate mx of scaphoid fx
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Nonunion and avascular necrosis; fx can block blood supply;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

21. conservative Tx of varicose veins
Unilateral vocal cord paralysis
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;
Compression stocking - weight reduction - leg elevation
Mammogram

22. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

23. beta hcg and AFP
Elevated non seminomas
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dm neuropathy; stocking glove pattern
Pure motor stroke; limited neurological dysfunction

24. inhalation of hot air - steam - smoke in burn victim
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Supraglottic edema; low threshold for intubation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Seminomas

25. Most common of sudden death due to steering wheel injury
Nonunion and avascular necrosis; fx can block blood supply;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

26. What is terrible triad
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
MAT; medial meniscus injury; ACL and Tibial colateral ligament

27. management of nondisplaced scaphoid fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Fx displace >1mm - nonunion during followup - osteonecrosis

28. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Amoxicillin-clavulanate
Headache - ataxia - bulbar dysfunction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

29. dorsiflexion and planter flexion
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;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
L5 to S2

30. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Saline and silicone
Retrograde ejaculation

31. Valgus and Varus tests
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
CRPS

32. 27 yo with scrotal mass; warm tender testes feel like bag of worms
10-12 months
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

33. recurrent laryngeal nerve injury
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
Mammogram
Carpal tunnel syndrom

34. How to confirm achiles tendon rupture
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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

35. What is the contraindication of hyperventilation in inc ICP
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Strok and traumatic brain injury

36. scrotal trauma
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Elderly and critically ill patients
Next best step surgery; not ultrasound

37. indication of ursodeoxycholic acid
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

38. pregnant patient with asymptomatic gall stones
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

39. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Meniscus injury; medial most common; pain/swelling; popping sensation
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;
Dm neuropathy; stocking glove pattern

40. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

41. anal sphincter tone
S2-S4
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

42. transrectal prostate biopsy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Progressive fibrosis of palmar fascia. etiololgy not known;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

43. complications of TPN
Brardycardia - HTN - resp depression
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
Compression stocking - weight reduction - leg elevation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

44. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
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

45. What is hungry bone syndrome?
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
Malignancy until proven otherwise
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

46. Patient underwent CABG; postoperatively drowsy. most likely cause?
24-48 hours of supportive therapy followed by 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pure motor stroke; limited neurological dysfunction

47. management of stone 8-10mm
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Epi and chest compressio for prolong period of time; atropine is given after epi;

48. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Saline and silicone
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

49. When goiter needs surgery
Malignancy until proven otherwise
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If any compressive symptoms eg. dysphagia

50. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
50%; tunneling between rectum or kin
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Brardycardia - HTN - resp depression