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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. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Amoxicillin-clavulanate
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

2. most common complication of acute cholecystitis
Mammogram
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

3. 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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Carpal tunnel syndrom
If patient ambulatory - surgery and pain control; if not nonop mx

4. aspiration of breast cyst is bloody
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Mammogram

5. most common fx when falling on outsretched hand
50%; tunneling between rectum or kin
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

6. scrotal trauma
Next best step surgery; not ultrasound
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

7. What is the strongest risk factor for male breast cancer
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Klinefelter syndrome; 50 fold increase;

8. management of nondisplaced scaphoid fx
Cystic scrotal fluid collection between parietal and visceral layers of testis
Nonunion and avascular necrosis; fx can block blood supply;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

9. How to confirm achiles tendon rupture
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

10. when patient with severe lung disease have C02 retention
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
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
Carpal tunnel syndrom
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

11. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Retrograde ejaculation
15-40%; self limiting;doesn't require tx
Dm neuropathy; stocking glove pattern
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. most frequent complication of TURP
24-48 hours of supportive therapy followed by cholecystectomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Retrograde ejaculation

13. Incidence of AF in CABG patient

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14. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
10-12 months

15. several knee pain after being tackled in football game
Study showed no adverse effect; but they are contraindicated for PVD
Ampicillin sublactum - pipercillin - ceftriaxone and metro
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

16. Tx of proximal non metastatic rectal ca
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Seminomas
Low anterior resection and radio; add chemo if node positive

17. When goiter needs surgery
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If any compressive symptoms eg. dysphagia
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

18. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Seminomas
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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;

19. How to confirm dx of compartment syndrom
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Unilateral vocal cord paralysis

20. surgery for acute cholecystities
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
4-6 weeks for noncontact sports and longer time for contact sports
10-12 months
24-48 hours of supportive therapy followed by cholecystectomy

21. diarrhoea after gastric bypass
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
If any compressive symptoms eg. dysphagia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dumping syndrome; small and frequent meals; no simple sugar

22. 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;
Check ET tube placement if correct needle decompresion
CRPS
Supraglottic edema; low threshold for intubation

23. How mcmurray manuver perform
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Abd pain and tenderness; bloody diarrhoea or hematochezia

24. varicocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

25. When do we see complications due to hypophosphatemia
Progressive fibrosis of palmar fascia. etiololgy not known;
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
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;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

26. transrectal prostate biopsy
Amoxicillin-clavulanate
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

27. What is the complications of undescended testis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Even after ochiopexy risk of ochiopexy higher then general population
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction

28. types of hip fracture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
50%; tunneling between rectum or kin

29. What is hungry bone syndrome?
24-48 hours of supportive therapy followed by cholecystectomy
50%; tunneling between rectum or kin
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

30. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
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. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

32. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

33. ct scan; cystic lesion in head of pancreas; next step
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pure motor stroke; limited neurological dysfunction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

34. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
SAH due to post communicating artery aneurysm;
Amoxicillin-clavulanate
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

35. 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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If patient ambulatory - surgery and pain control; if not nonop mx

36. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Increased size during the day and valsalva means it is communicated with peritoneal cavity

37. How to evaluate painless testicular swelling suspicious for cancer
Saline and silicone
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

38. how hyperventilation lowers ICP
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

39. Patient underwent CABG; postoperatively drowsy. most likely cause?
10-12 months
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
50%; tunneling between rectum or kin

40. management of gunshot wound
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Nonunion and avascular necrosis; fx can block blood supply;
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

41. What are the common injuries from lightning?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Next best step surgery; not ultrasound
Check ET tube placement if correct needle decompresion
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

42. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Mammogram
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

43. mx of stress fx
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Klinefelter syndrome; 50 fold increase;

44. Valgus and Varus tests
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;
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

45. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Ispilateral hypoglossal nerve injury
Patellar tendon tear; difficulty in extension
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

46. Why right varicocele is more concerning?

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47. differential of ultrasound finding of breast mass
If any compressive symptoms eg. dysphagia
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
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

48. ipsilateral deviation of tongue upon protrusion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ispilateral hypoglossal nerve injury
Mammogram
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

49. what size of ureteral stone for non op mx
Amoxicillin-clavulanate
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Less than 5mm

50. indication of ursodeoxycholic acid
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;
4-6 weeks for noncontact sports and longer time for contact sports
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
Nonunion and avascular necrosis; fx can block blood supply;