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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. cremasteric reflex
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

2. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
10-12 months
Nonunion and avascular necrosis; fx can block blood supply;

3. diarrhoea 4-5 days after cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

4. Incidence of AF in CABG patient

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5. suprapubic catheterization
When urethral catherization is unsuccessful
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If patient ambulatory - surgery and pain control; if not nonop mx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

6. 3 mo with groin bulge; bulge appears when child cries
Malignancy until proven otherwise
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

7. dorsiflexion and planter flexion
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
L5 to S2
Ispilateral hypoglossal nerve injury

8. What time frame required for bone remodeling
Saline and silicone
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
10-12 months
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

9. lacerated wound in palmer surface of hand. what structure is injured?
Retrograde ejaculation
Tendons more likely
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

10. most common fx when falling on outsretched hand
Ispilateral hypoglossal nerve injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Seminomas
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

11. what size of ureteral stone for non op mx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Less than 5mm

12. beta hcg and AFP
Elevated non seminomas
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If any compressive symptoms eg. dysphagia
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

13. antibiotics of acute cholecystitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Tendons more likely

14. How to confirm dx of compartment syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Brardycardia - HTN - resp depression
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Compression stocking - weight reduction - leg elevation

15. xray finding of stress fx after 3-4w
Cystic scrotal fluid collection between parietal and visceral layers of testis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elderly and critically ill patients
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

16. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
When urethral catherization is unsuccessful
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

17. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Subphrenic abscess or other abdominal abscesses; order US or CT
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Nonunion and avascular necrosis; fx can block blood supply;
Dm neuropathy; stocking glove pattern

18. Indication for bariatric surgery in obese patients
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;
Ispilateral hypoglossal nerve injury

19. management of gunshot wound
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

20. mangement of localized lymphadenopathy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Ampicillin sublactum - pipercillin - ceftriaxone and metro

21. management of nondisplaced scaphoid fx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

22. Why varicocele more common in the left side
Meniscus injury; medial most common; pain/swelling; popping sensation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

23. cat/dog bites
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dumping syndrome; small and frequent meals; no simple sugar
Amoxicillin-clavulanate
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

24. Valgus and Varus tests
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Supraglottic edema; low threshold for intubation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Urethral stricture; pelvic of urethral trauma

25. common complication of inadequate mx of scaphoid fx
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Nonunion and avascular necrosis; fx can block blood supply;

26. midline neck swelling moves with protrusion of tongue
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Mammogram
Ispilateral hypoglossal nerve injury

27. varicocele
Strok and traumatic brain injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Low anterior resection and radio; add chemo if node positive

28. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
L5 to S2
15-40%; self limiting;doesn't require tx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

29. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

30. When to do surgery in undesceneded testis?
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
15-40%; self limiting;doesn't require tx
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

31. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Check ET tube placement if correct needle decompresion
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

32. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

33. tx distal rectal ca
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sphincter sparing surgery (local resection) - abdomnio perineal resection

34. How to confirm achiles tendon rupture
When urethral catherization is unsuccessful
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Malignancy until proven otherwise

35. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Increased size during the day and valsalva means it is communicated with peritoneal cavity
4-6 weeks for noncontact sports and longer time for contact sports
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

36. surgery for acute cholecystities
Twisting force with the foot fixed on the ground seen in football and basketball games;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
24-48 hours of supportive therapy followed by cholecystectomy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. menisci injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Seminomas
Compression stocking - weight reduction - leg elevation
Twisting force with the foot fixed on the ground seen in football and basketball games;

38. differential of ultrasound finding of breast mass
Twisting force with the foot fixed on the ground seen in football and basketball games;
Ispilateral hypoglossal nerve 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
Meniscus injury; medial most common; pain/swelling; popping sensation

39. 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)
4-6 weeks for noncontact sports and longer time for contact sports
15-40%; self limiting;doesn't require tx
Unilateral vocal cord paralysis

40. most frequent complication of TURP
Retrograde ejaculation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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

41. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Patellar tendon tear; difficulty in extension
Dm neuropathy; stocking glove pattern
24-48 hours of supportive therapy followed by cholecystectomy

42. anal sphincter tone
If any compressive symptoms eg. dysphagia
If patient ambulatory - surgery and pain control; if not nonop mx
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
S2-S4

43. Most common of sudden death due to steering wheel injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Mammogram
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

44. clavicle fx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Displaced ORIF ; nondisplaced sling immobilization
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

45. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Low anterior resection and radio; add chemo if node positive
Study showed no adverse effect; but they are contraindicated for PVD
Subphrenic abscess or other abdominal abscesses; order US or CT
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

46. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

47. How to manage obesity
Next best step surgery; not ultrasound
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
CRPS
Progressive fibrosis of palmar fascia. etiololgy not known;

48. What is the contraindication of hyperventilation in inc ICP
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
24-48 hours of supportive therapy followed by cholecystectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament

49. How to manage a patient with asystole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Progressive fibrosis of palmar fascia. etiololgy not known;
Epi and chest compressio for prolong period of time; atropine is given after epi;
CRPS

50. transrectal prostate biopsy
Amoxicillin-clavulanate
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Compression stocking - weight reduction - leg elevation
MAT; medial meniscus injury; ACL and Tibial colateral ligament