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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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Amoxicillin-clavulanate
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

2. What is most common lung injury after blunt chest trauma?
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

3. stress fx
CRPS
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
15-40%; self limiting;doesn't require tx
If patient ambulatory - surgery and pain control; if not nonop mx

4. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

5. Indication for bariatric surgery in obese patients
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;
Low anterior resection and radio; add chemo if node positive
Compression stocking - weight reduction - leg elevation

6. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Subphrenic abscess or other abdominal abscesses; order US or CT
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

7. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Progressive fibrosis of palmar fascia. etiololgy not known;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Malignancy until proven otherwise

8. ipsilateral deviation of tongue upon protrusion
If any compressive symptoms eg. dysphagia
Ispilateral hypoglossal nerve injury
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;
4-6 weeks for noncontact sports and longer time for contact sports

9. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Ampicillin sublactum - pipercillin - ceftriaxone and metro

10. Why varicocele more common in the left side
15-40%; self limiting;doesn't require tx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

11. Most common of sudden death due to steering wheel injury
Nonunion and avascular necrosis; fx can block blood supply;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

12. varicose veins with ulcer - bleeding and thrombophlebitits
50%; tunneling between rectum or kin
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Brardycardia - HTN - resp depression
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

13. diarrhoea after gastric bypass
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Dumping syndrome; small and frequent meals; no simple sugar

14. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Unilateral vocal cord paralysis
4-6 weeks for noncontact sports and longer time for contact sports
CRPS
SAH due to post communicating artery aneurysm;

15. Dupuytren contracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
15-40%; self limiting;doesn't require tx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Progressive fibrosis of palmar fascia. etiololgy not known;

16. suprapubic catheterization
When urethral catherization is unsuccessful
Cystic scrotal fluid collection between parietal and visceral layers of testis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Seminomas

17. What is the contraindication of hyperventilation in inc ICP
Progressive fibrosis of palmar fascia. etiololgy not known;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Strok and traumatic brain injury
Less than 5mm

18. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Displaced ORIF ; nondisplaced sling immobilization
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

19. most frequent complication of TURP
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;
Retrograde ejaculation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check ET tube placement if correct needle decompresion

20. how hyperventilation lowers ICP
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
Less than 5mm
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

21. Tx of proximal non metastatic rectal ca
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)
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Low anterior resection and radio; add chemo if node positive

22. Why right varicocele is more concerning?

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23. How to dx ACL tear?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

24. when patient with severe lung disease have C02 retention
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal 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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

25. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

26. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

27. severe pain in leg after MVC
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
Dumping syndrome; small and frequent meals; no simple sugar
Seminomas
Displaced ORIF ; nondisplaced sling immobilization

28. scrotal trauma
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Next best step surgery; not ultrasound
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
24-48 hours of supportive therapy followed by cholecystectomy

29. What are the common injuries from lightning?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
MAT; medial meniscus injury; ACL and Tibial colateral ligament

30. characteristics of ureteral stone?
L5 to S2
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

31. inhalation of hot air - steam - smoke in burn victim
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Pure motor stroke; limited neurological dysfunction
Supraglottic edema; low threshold for intubation

32. cat/dog bites
Patellar tendon tear; difficulty in extension
Amoxicillin-clavulanate
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

33. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
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;

34. pregnant patient with asymptomatic gall stones
Carpal tunnel syndrom
Epi and chest compressio for prolong period of time; atropine is given after epi;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

35. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
SAH due to post communicating artery aneurysm;
Brardycardia - HTN - resp depression
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dm neuropathy; stocking glove pattern

36. Incidence of AF in CABG patient

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37. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
4-6 weeks for noncontact sports and longer time for contact sports
Malignancy until proven otherwise
Dumping syndrome; small and frequent meals; no simple sugar

38. dorsiflexion and planter flexion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2
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
Amoxicillin-clavulanate

39. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mammogram
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

40. first line of management of PVD
Brardycardia - HTN - resp depression
If patient ambulatory - surgery and pain control; if not nonop mx
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

41. indication of ursodeoxycholic acid
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
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
50%; tunneling between rectum or kin

42. What is hydrocele?
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
L5 to S2

43. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound
Subphrenic abscess or other abdominal abscesses; order US or CT

44. beta HCG
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Seminomas
Unilateral vocal cord paralysis

45. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Check ET tube placement if correct needle decompresion

46. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
ACL injury

47. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Klinefelter syndrome; 50 fold increase;
Compression stocking - weight reduction - leg elevation
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

48. How to confirm achiles tendon rupture
Mammogram
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
Tendons more likely

49. What is hungry bone syndrome?
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Displaced ORIF ; nondisplaced sling immobilization

50. How to confirm dx of compartment syndrom
Brardycardia - HTN - resp depression
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy