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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. Valgus and Varus tests
Abd pain and tenderness; bloody diarrhoea or hematochezia
Meniscus injury; medial most common; pain/swelling; popping sensation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

2. lacerated wound in palmer surface of hand. what structure is injured?
Fx displace >1mm - nonunion during followup - osteonecrosis
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;
Tendons more likely
Displaced ORIF ; nondisplaced sling immobilization

3. mangement of localized lymphadenopathy
Study showed no adverse effect; but they are contraindicated for PVD
Check ET tube placement if correct needle decompresion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

4. surgery for acute cholecystities
Elderly and critically ill patients
24-48 hours of supportive therapy followed by cholecystectomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Increased size during the day and valsalva means it is communicated with peritoneal cavity

5. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
SAH due to post communicating artery aneurysm;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

6. Dupuytren contracture
Compression stocking - weight reduction - leg elevation
Less than 5mm
Urethral stricture; pelvic of urethral trauma
Progressive fibrosis of palmar fascia. etiololgy not known;

7. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
ACL injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Low anterior resection and radio; add chemo if node positive

8. What is hungry bone syndrome?
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
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

9. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

10. How varicocele causes testicular atrophy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

11. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

12. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Study showed no adverse effect; but they are contraindicated for PVD

13. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Check ET tube placement if correct needle decompresion
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Increased size during the day and valsalva means it is communicated with peritoneal cavity

14. How to dx ACL tear?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
CRPS
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

15. beta HCG
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Elderly and critically ill patients
Seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

16. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Urethral stricture; pelvic of urethral trauma
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Elderly and critically ill patients

17. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Even after ochiopexy risk of ochiopexy higher then general population
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

18. Why varicocele more common in the left side
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Patellar tendon tear; difficulty in extension
Epi and chest compressio for prolong period of time; atropine is given after epi;

19. varicose veins with ulcer - bleeding and thrombophlebitits
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

20. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Study showed no adverse effect; but they are contraindicated for PVD
50%; tunneling between rectum or kin

21. Why initial xrays are negative in scaphoid fx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Low anterior resection and radio; add chemo if node positive

22. common complication of inadequate mx of scaphoid fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Klinefelter syndrome; 50 fold increase;
Nonunion and avascular necrosis; fx can block blood supply;

23. cremasteric reflex 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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

24. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Nonunion and avascular necrosis; fx can block blood supply;

25. anal sphincter tone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
S2-S4

26. scrotal trauma
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Next best step surgery; not ultrasound
Carpal tunnel syndrom

27. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
15-40%; self limiting;doesn't require tx
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

28. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
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
Displaced ORIF ; nondisplaced sling immobilization
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

29. When goiter needs surgery
Saline and silicone
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Next best step surgery; not ultrasound
If any compressive symptoms eg. dysphagia

30. When patient can go back to sports after clavicle fx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
4-6 weeks for noncontact sports and longer time for contact sports
Fx displace >1mm - nonunion during followup - osteonecrosis

31. When to stop raloxifene before surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Strok and traumatic brain injury
Less than 5mm
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

32. When do we see complications due to hypophosphatemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevated non seminomas

33. varicocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

34. lacunar stroke
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
Pure motor stroke; limited neurological dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

35. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Unilateral vocal cord paralysis
L5 to S2

36. sudden onset of postoperative hyperglycemia when patient on TPN
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
10-12 months
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;

37. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Study showed no adverse effect; but they are contraindicated for PVD

38. Incidence of AF in CABG patient

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39. complications of TPN
Carpal tunnel syndrom
Mammogram
Brardycardia - HTN - resp depression
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

40. 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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

41. 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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Strok and traumatic brain injury

42. Indication for bariatric surgery in obese patients
Supraglottic edema; low threshold for intubation
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;
Progressive fibrosis of palmar fascia. etiololgy not known;
Mammogram

43. What is terrible triad
Brardycardia - HTN - resp depression
Patellar tendon tear; difficulty in extension
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

44. 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)
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Even after ochiopexy risk of ochiopexy higher then general population
L5 to S2

45. Tx of proximal non metastatic rectal ca
Seminomas
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
Displaced ORIF ; nondisplaced sling immobilization
Low anterior resection and radio; add chemo if node positive

46. management of gunshot wound
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
Headache - ataxia - bulbar dysfunction
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
MAT; medial meniscus injury; ACL and Tibial colateral ligament

47. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

48. Tx of pulmonary contusion
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

49. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dm neuropathy; stocking glove pattern

50. What is the strongest risk factor for male breast cancer
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Klinefelter syndrome; 50 fold increase;