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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
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

2. perioral numbness after parathyroidectomy
15-40%; self limiting;doesn't require tx
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
24-48 hours of supportive therapy followed by cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization

3. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Amoxicillin-clavulanate
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Less than 5mm

4. acalculus cholecystitis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Elderly and critically ill patients

5. management of stone 8-10mm
Retrograde ejaculation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Supraglottic edema; low threshold for intubation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

6. Why ruq calcificaion is concerning
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Malignancy until proven otherwise

7. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

8. severe pain in leg after MVC
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

9. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Ispilateral hypoglossal nerve injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

10. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Amoxicillin-clavulanate

11. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
15-40%; self limiting;doesn't require tx
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

12. most common fx when falling on outsretched hand
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Epi and chest compressio for prolong period of time; atropine is given after epi;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

13. How to confirm achiles tendon rupture
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevated non seminomas

14. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Mammogram
24-48 hours of supportive therapy followed by cholecystectomy
Amoxicillin-clavulanate

15. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

16. types of hip fracture
Supraglottic edema; low threshold for intubation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Mammogram
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

17. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Progressive fibrosis of palmar fascia. etiololgy not known;
Displaced ORIF ; nondisplaced sling immobilization

18. What percent of anal abscess deveolop fisutula
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
50%; tunneling between rectum or kin
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis

19. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
When urethral catherization is unsuccessful
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

20. managment of animal bite in hands
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Saline and silicone
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

21. scrotal trauma
Next best step surgery; not ultrasound
Ispilateral hypoglossal nerve injury
CRPS
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

22. management of hip fracture
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
Compression stocking - weight reduction - leg elevation
If patient ambulatory - surgery and pain control; if not nonop mx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

23. beta hcg and AFP
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization

24. What is hungry bone syndrome?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mammogram
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

25. SOB - confusion - petechial rash after trauma - fracture
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
L5 to S2

26. surgery for acute cholecystities
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
24-48 hours of supportive therapy followed by cholecystectomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

27. differential of ultrasound finding of breast mass
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Supraglottic edema; low threshold for intubation
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

28. anal sphincter tone
S2-S4
Dm neuropathy; stocking glove pattern
Epi and chest compressio for prolong period of time; atropine is given after epi;
Less than 5mm

29. Why right varicocele is more concerning?

30. How to differentiate communicative and non-communicative hydrocele
Subphrenic abscess or other abdominal abscesses; order US or CT
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

31. aspiration of breast cyst is bloody
Mammogram
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

32. Why initial xrays are negative in scaphoid fx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Low anterior resection and radio; add chemo if node positive
Klinefelter syndrome; 50 fold increase;
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

33. How to differentiate ACL and meniscus injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

34. What is the strongest risk factor for male breast cancer
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Klinefelter syndrome; 50 fold increase;
Meniscus injury; medial most common; pain/swelling; popping sensation

35. varicocele
Cystic scrotal fluid collection between parietal and visceral layers of testis
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

36. How to manage obesity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Next best step surgery; not ultrasound
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Seminomas

37. clavicle fx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Supraglottic edema; low threshold for intubation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Displaced ORIF ; nondisplaced sling immobilization

38. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Progressive fibrosis of palmar fascia. etiololgy not known;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Saline and silicone

39. contraindication of urethral catheterization
If any compressive symptoms eg. dysphagia
Urethral stricture; pelvic of urethral trauma
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

40. conservative Tx of varicose veins
Strok and traumatic brain injury
Compression stocking - weight reduction - leg elevation
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
Displaced ORIF ; nondisplaced sling immobilization

41. What is cushing's triad
Brardycardia - HTN - resp depression
Strok and traumatic brain injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

42. What is the complications of undescended testis
Patellar tendon tear; difficulty in extension
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Even after ochiopexy risk of ochiopexy higher then general population
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

43. stress fx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

44. What are the common injuries from lightning?
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

45. What is prehn sign?
ACL injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Carpal tunnel syndrom
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

46. what size of ureteral stone for non op mx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Less than 5mm
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Seminomas

47. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Malignancy until proven otherwise
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. mangement of localized lymphadenopathy
Carpal tunnel syndrom
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

49. painless testicular mass in young male
Malignancy until proven otherwise
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia
L5 to S2

50. Tx of pulmonary contusion
Twisting force with the foot fixed on the ground seen in football and basketball games;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case