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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. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
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

2. cat/dog bites
Amoxicillin-clavulanate
Cystic scrotal fluid collection between parietal and visceral layers of testis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Brardycardia - HTN - resp depression

3. management of nondisplaced scaphoid fx
Progressive fibrosis of palmar fascia. etiololgy not known;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Seminomas
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

4. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
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
ACL injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

5. What are the common injuries from lightning?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

6. acalculus cholecystitis
Nonunion and avascular necrosis; fx can block blood supply;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Elderly and critically ill patients

7. most common fx when falling on outsretched hand
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis
50%; tunneling between rectum or kin
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

8. common complication of inadequate mx of scaphoid fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Nonunion and avascular necrosis; fx can block blood supply;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

9. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fx displace >1mm - nonunion during followup - osteonecrosis
24-48 hours of supportive therapy followed by cholecystectomy
ACL injury

10. How varicocele causes testicular atrophy
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Patellar tendon tear; difficulty in extension

11. aspiration of breast cyst is nonbloody
Nonunion and avascular necrosis; fx can block blood supply;
Check ET tube placement if correct needle decompresion
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

12. How to differentiate ACL and meniscus injury
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
L5 to S2
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

13. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Subphrenic abscess or other abdominal abscesses; order US or CT
Dm neuropathy; stocking glove pattern
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

14. scrotal trauma
Next best step surgery; not ultrasound
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
When urethral catherization is unsuccessful
ACL injury

15. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
SAH due to post communicating artery aneurysm;
Supraglottic edema; low threshold for intubation

16. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

17. Complications of breast impant
Low anterior resection and radio; add chemo if node positive
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

18. first line of management of PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

19. beta hcg and AFP
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Elevated non seminomas

20. beta HCG
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Seminomas
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
Strok and traumatic brain injury

21. How to dx ACL tear?
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

22. What types of breast implants are available
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
Displaced ORIF ; nondisplaced sling immobilization
Saline and silicone

23. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

24. suprapubic catheterization
When urethral catherization is unsuccessful
Subphrenic abscess or other abdominal abscesses; order US or CT
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Supraglottic edema; low threshold for intubation

25. 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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
MAT; medial meniscus injury; ACL and Tibial colateral ligament

26. dumping syndrome after gastrectomy
Patellar tendon tear; difficulty in extension
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Strok and traumatic brain injury

27. management of stone 8-10mm
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

28. mangement of localized lymphadenopathy
Low anterior resection and radio; add chemo if node positive
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

29. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elderly and critically ill patients

30. Indication for bariatric surgery in obese patients
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;
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 any compressive symptoms eg. dysphagia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

31. indication of ursodeoxycholic acid
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Subphrenic abscess or other abdominal abscesses; order US or CT

32. cremasteric reflex test?
S2-S4
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

33. When goiter needs surgery
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Unilateral vocal cord paralysis
If any compressive symptoms eg. dysphagia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

34. what size of ureteral stone for non op mx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Less than 5mm

35. When do we see complications due to hypophosphatemia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
15-40%; self limiting;doesn't require tx
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

36. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Compression stocking - weight reduction - leg elevation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

37. How mcmurray manuver perform
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

38. complication displaced or communited distal radial fx
Seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Carpal tunnel syndrom
Tendons more likely

39. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

40. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Dumping syndrome; small and frequent meals; no simple sugar
15-40%; self limiting;doesn't require tx

41. diarrhoea 4-5 days after cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

42. most common complication of acute cholecystitis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. What is most common lung injury after blunt chest trauma?
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

44. how ABI help dx of PVD
Subphrenic abscess or other abdominal abscesses; order US or CT
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

45. anal sphincter tone
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
S2-S4
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

46. painless testicular mass in young male
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Malignancy until proven otherwise
ACL injury

47. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Subphrenic abscess or other abdominal abscesses; order US or CT
Klinefelter syndrome; 50 fold increase;
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
Dm neuropathy; stocking glove pattern

48. characteristics of ureteral stone?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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. Dupuytren contracture
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

50. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
4-6 weeks for noncontact sports and longer time for contact sports
CRPS
Tendons more likely
Check ET tube placement if correct needle decompresion