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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. beta HCG
Displaced ORIF ; nondisplaced sling immobilization
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

2. inhalation of hot air - steam - smoke in burn victim
10-12 months
Supraglottic edema; low threshold for intubation
Less than 5mm
Headache - ataxia - bulbar dysfunction

3. When goiter needs surgery
If any compressive symptoms eg. dysphagia
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

4. complications of TPN
Saline and silicone
24-48 hours of supportive therapy followed by cholecystectomy
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

5. varicose veins with ulcer - bleeding and thrombophlebitits
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dumping syndrome; small and frequent meals; no simple sugar

6. When to do surgery in undesceneded testis?
Seminomas
10-12 months
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

7. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dm neuropathy; stocking glove pattern
Klinefelter syndrome; 50 fold increase;
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

8. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cystic scrotal fluid collection between parietal and visceral layers of testis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Headache - ataxia - bulbar dysfunction

9. diarrhoea after gastric bypass
Mammogram
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dumping syndrome; small and frequent meals; no simple sugar

10. scrotal trauma
Next best step surgery; not ultrasound
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Malignancy until proven otherwise

11. aspiration of breast cyst is bloody
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
Mammogram
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
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
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
Dm neuropathy; stocking glove pattern

13. How to manage obesity
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Low anterior resection and radio; add chemo if node positive
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If patient ambulatory - surgery and pain control; if not nonop mx

14. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Elderly and critically ill patients
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Next best step surgery; not ultrasound

15. how ABI help dx of PVD
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

16. 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
S2-S4
Twisting force with the foot fixed on the ground seen in football and basketball games;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

17. most common complication of acute cholecystitis
Subphrenic abscess or other abdominal abscesses; order US or CT
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

18. What is terrible triad
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dumping syndrome; small and frequent meals; no simple sugar

19. types of hip fracture
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

20. What is the contraindication of hyperventilation in inc ICP
Next best step surgery; not ultrasound
Strok and traumatic brain injury
Compression stocking - weight reduction - leg elevation
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

21. beta hcg and AFP
Elevated non seminomas
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

22. cremasteric reflex test?
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

23. What is prehn sign?
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Supraglottic edema; low threshold for intubation
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

24. differential of ultrasound finding of breast mass
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

25. indication of ursodeoxycholic acid
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
Amoxicillin-clavulanate

26. perioral numbness after parathyroidectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ispilateral hypoglossal nerve injury
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
Dumping syndrome; small and frequent meals; no simple sugar

27. management of nondisplaced scaphoid fx
Displaced ORIF ; nondisplaced sling immobilization
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

28. What is the strongest risk factor for male breast cancer
Fx displace >1mm - nonunion during followup - osteonecrosis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Klinefelter syndrome; 50 fold increase;
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

29. clavicle fx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Displaced ORIF ; nondisplaced sling immobilization
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

30. menisci injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

31. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Supraglottic edema; low threshold for intubation

32. How to evaluate painless testicular swelling suspicious for cancer
Meniscus injury; medial most common; pain/swelling; popping sensation
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
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

33. management of gunshot wound
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Seminomas

34. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dumping syndrome; small and frequent meals; no simple sugar
When urethral catherization is unsuccessful

35. dorsiflexion and planter flexion
Dm neuropathy; stocking glove pattern
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
L5 to S2

36. How to perform lachman test
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Less than 5mm
Dumping syndrome; small and frequent meals; no simple sugar
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

37. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
10-12 months
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

38. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

39. managment of animal bite in hands
Epi and chest compressio for prolong period of time; atropine is given after epi;
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Urethral stricture; pelvic of urethral trauma

40. Why varicocele more common in the left side
Ispilateral hypoglossal nerve injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Even after ochiopexy risk of ochiopexy higher then general population

41. Why initial xrays are negative in scaphoid fx
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fx displace >1mm - nonunion during followup - osteonecrosis
Carpal tunnel syndrom

42. stress fx
Amoxicillin-clavulanate
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Even after ochiopexy risk of ochiopexy higher then general population
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

43. varicocele
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;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Less than 5mm

44. When do we see complications due to hypophosphatemia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Tendons more likely
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

45. What is hydrocele?
Saline and silicone
Cystic scrotal fluid collection between parietal and visceral layers of testis
If any compressive symptoms eg. dysphagia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

46. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

47. surgery for acute cholecystities
Ispilateral hypoglossal nerve injury
L5 to S2
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
24-48 hours of supportive therapy followed by cholecystectomy

48. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Headache - ataxia - bulbar dysfunction

49. characteristics of ureteral stone?
Study showed no adverse effect; but they are contraindicated for PVD
L5 to S2
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

50. severe pain in leg after MVC
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;