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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. scrotal trauma
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Next best step surgery; not ultrasound
S2-S4
Supraglottic edema; low threshold for intubation

2. diarrhoea after gastric bypass
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dumping syndrome; small and frequent meals; no simple sugar
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If any compressive symptoms eg. dysphagia

3. complications of TPN
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

4. complication displaced or communited distal radial fx
Pure motor stroke; limited neurological dysfunction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Carpal tunnel syndrom

5. stress fx
Supraglottic edema; low threshold for intubation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

6. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Retrograde ejaculation
Supraglottic edema; low threshold for intubation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

7. What are the common injuries from lightning?
Progressive fibrosis of palmar fascia. etiololgy not known;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Amoxicillin-clavulanate
Retrograde ejaculation

8. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

9. What types of breast implants are available
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Saline and silicone
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

10. Tx of pulmonary contusion
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

11. ipsilateral deviation of tongue upon protrusion
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Next best step surgery; not ultrasound
When urethral catherization is unsuccessful
Ispilateral hypoglossal nerve injury

12. dumping syndrome after gastrectomy
Klinefelter syndrome; 50 fold increase;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Patellar tendon tear; difficulty in extension

13. What is the complications of undescended testis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Even after ochiopexy risk of ochiopexy higher then general population
Progressive fibrosis of palmar fascia. etiololgy not known;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

14. Patient underwent CABG; postoperatively drowsy. most likely cause?
24-48 hours of supportive therapy followed by cholecystectomy
Carpal tunnel syndrom
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

15. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

16. painless testicular mass in young male
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Malignancy until proven otherwise
Saline and silicone

17. Why varicocele more common in the left side
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Less than 5mm

18. How to evaluate painless testicular swelling suspicious for cancer
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dumping syndrome; small and frequent meals; no simple sugar
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

19. dorsiflexion and planter flexion
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
15-40%; self limiting;doesn't require tx
L5 to S2

20. anal sphincter tone
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
S2-S4
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

21. How to manage obesity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Meniscus injury; medial most common; pain/swelling; popping sensation
Seminomas

22. first step for evaluation of testicular swelling
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Nonunion and avascular necrosis; fx can block blood supply;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If any compressive symptoms eg. dysphagia

23. Can we use beta blocker for pvd?
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Study showed no adverse effect; but they are contraindicated for PVD
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

24. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Meniscus injury; medial most common; pain/swelling; popping sensation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
MAT; medial meniscus injury; ACL and Tibial colateral ligament

25. acalculus cholecystitis
Patellar tendon tear; difficulty in extension
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elderly and critically ill patients

26. mangement of localized lymphadenopathy
4-6 weeks for noncontact sports and longer time for contact sports
Abd pain and tenderness; bloody diarrhoea or hematochezia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

27. surgery for acute cholecystities
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole
24-48 hours of supportive therapy followed by cholecystectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament

28. Why initial xrays are negative in scaphoid fx
Amoxicillin-clavulanate
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
ACL injury
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

29. clavicle fx
SAH due to post communicating artery aneurysm;
Less than 5mm
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Displaced ORIF ; nondisplaced sling immobilization

30. xray finding of stress fx after 3-4w
Study showed no adverse effect; but they are contraindicated for PVD
SAH due to post communicating artery aneurysm;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

31. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
CRPS
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dm neuropathy; stocking glove pattern

32. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

33. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Saline and silicone
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Fx displace >1mm - nonunion during followup - osteonecrosis

34. SOB - confusion - petechial rash after trauma - fracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Saline and silicone
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

35. suprapubic catheterization
When urethral catherization is unsuccessful
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Carpal tunnel syndrom

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

37. lacerated wound in palmer surface of hand. what structure is injured?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
10-12 months
Tendons more likely

38. most common fx when falling on outsretched hand
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
Displaced ORIF ; nondisplaced sling immobilization
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

39. when scaphoid fx patient needs to be referred to orthopedic
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Fx displace >1mm - nonunion during followup - osteonecrosis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Progressive fibrosis of palmar fascia. etiololgy not known;

40. diarrhoea 4-5 days after cholecystectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

41. sudden onset of postoperative hyperglycemia when patient on TPN
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Brardycardia - HTN - resp depression

42. beta HCG
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Check ET tube placement if correct needle decompresion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Seminomas

43. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Unilateral vocal cord paralysis
Even after ochiopexy risk of ochiopexy higher then general population

44. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

45. What is most common lung injury after blunt chest trauma?
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Saline and silicone
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

46. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Malignancy until proven otherwise
Carpal tunnel syndrom
MAT; medial meniscus injury; ACL and Tibial colateral ligament

47. several knee pain after being tackled in football game
Nonunion and avascular necrosis; fx can block blood supply;
Saline and silicone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

48. contraindication of urethral catheterization
Saline and silicone
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Urethral stricture; pelvic of urethral trauma
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;

49. When patient can go back to sports after clavicle fx
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
4-6 weeks for noncontact sports and longer time for contact sports
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

50. managment of animal bite in hands
Seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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)