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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. Can we use beta blocker for pvd?
L5 to S2
Elevated non seminomas
Amoxicillin-clavulanate
Study showed no adverse effect; but they are contraindicated for PVD

2. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

3. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Less than 5mm
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

4. What is hydrocele?
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis
ACL injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

5. How to perform lachman test
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
Elderly and critically ill patients
Nonunion and avascular necrosis; fx can block blood supply;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

6. Patient underwent CABG; postoperatively drowsy. most likely cause?
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

7. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Cystic scrotal fluid collection between parietal and visceral layers of testis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

8. menisci injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Retrograde ejaculation

9. perioral numbness after parathyroidectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury

10. ipsilateral deviation of tongue upon protrusion
Check ET tube placement if correct needle decompresion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ispilateral hypoglossal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar

11. Most common of sudden death due to steering wheel injury
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
ACL injury

12. aspiration of breast cyst is nonbloody
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Meniscus injury; medial most common; pain/swelling; popping sensation
Check ET tube placement if correct needle decompresion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

13. indication of ursodeoxycholic acid
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
15-40%; self limiting;doesn't require tx
Progressive fibrosis of palmar fascia. etiololgy not known;

14. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

15. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
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

16. managment of animal bite in hands
Elderly and critically ill patients
Dumping syndrome; small and frequent meals; no simple sugar
Seminomas
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;

17. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Urethral stricture; pelvic of urethral trauma
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

18. diarrhoea after gastric bypass
Compression stocking - weight reduction - leg elevation
15-40%; self limiting;doesn't require tx
Dumping syndrome; small and frequent meals; no simple sugar
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

19. mx of stress fx
Tendons more likely
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Malignancy until proven otherwise

20. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
S2-S4

21. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Carpal tunnel syndrom
CRPS
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

22. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Amoxicillin-clavulanate
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

23. What time frame required for bone remodeling
Pure motor stroke; limited neurological dysfunction
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
10-12 months
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

24. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
L5 to S2
15-40%; self limiting;doesn't require tx

25. Incidence of AF in CABG patient

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26. When goiter needs surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If any compressive symptoms eg. dysphagia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

27. cremasteric reflex
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dm neuropathy; stocking glove pattern

28. aspiration of breast cyst is bloody
Mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dm neuropathy; stocking glove pattern

29. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
L5 to S2
15-40%; self limiting;doesn't require tx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

30. several knee pain after being tackled in football game
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Saline and silicone
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Dumping syndrome; small and frequent meals; no simple sugar

31. When patient can go back to sports after clavicle fx
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
4-6 weeks for noncontact sports and longer time for contact sports

32. most frequent complication of TURP
Retrograde ejaculation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
4-6 weeks for noncontact sports and longer time for contact sports
ACL injury

33. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
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
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

34. acute colonic ischemia
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
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

35. Indication for bariatric surgery in obese patients
Klinefelter syndrome; 50 fold increase;
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
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;

36. inhalation of hot air - steam - smoke in burn victim
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Supraglottic edema; low threshold for intubation

37. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Displaced ORIF ; nondisplaced sling immobilization
Sphincter sparing surgery (local resection) - abdomnio perineal resection

38. swelling and tenderness in anterior part of knee
Unilateral vocal cord paralysis
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
Patellar tendon tear; difficulty in extension

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
4-6 weeks for noncontact sports and longer time for contact sports
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
L5 to S2

40. Complications of breast impant
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

41. painless testicular mass in young male
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Malignancy until proven otherwise

42. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
15-40%; self limiting;doesn't require tx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
When urethral catherization is unsuccessful

43. scrotal trauma
Carpal tunnel syndrom
CRPS
Next best step surgery; not ultrasound
Nonunion and avascular necrosis; fx can block blood supply;

44. What is hungry bone syndrome?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Malignancy until proven otherwise
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

45. contraindication of urethral catheterization
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
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
Urethral stricture; pelvic of urethral trauma

46. pregnant patient with asymptomatic gall stones
Compression stocking - weight reduction - leg elevation
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

47. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
CRPS

48. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;

49. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Dm neuropathy; stocking glove pattern
Patellar tendon tear; difficulty in extension
Next best step surgery; not ultrasound

50. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;