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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. popping sensation; rapid onset of knee effusion. athelet
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
L5 to S2
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
ACL injury

2. What is cushing's triad
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Headache - ataxia - bulbar dysfunction
Brardycardia - HTN - resp depression

3. Why right varicocele is more concerning?

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4. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dm neuropathy; stocking glove pattern

5. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Dm neuropathy; stocking glove pattern
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

6. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Study showed no adverse effect; but they are contraindicated for PVD
Patellar tendon tear; difficulty in extension
Pure motor stroke; limited neurological dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation

7. What is hungry bone syndrome?
Abd pain and tenderness; bloody diarrhoea or hematochezia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
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;

8. dumping syndrome after gastrectomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

9. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Unilateral vocal cord paralysis
S2-S4
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

10. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

11. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

12. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If patient ambulatory - surgery and pain control; if not nonop mx

13. When do we see complications due to hypophosphatemia
Next best step surgery; not ultrasound
Twisting force with the foot fixed on the ground seen in football and basketball games;
Headache - ataxia - bulbar dysfunction
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;

14. severe pain in leg after MVC
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

15. 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
Fx displace >1mm - nonunion during followup - osteonecrosis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

16. beta hcg and AFP
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Elevated non seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;
Next best step surgery; not ultrasound

17. Dupuytren contracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Subphrenic abscess or other abdominal abscesses; order US or CT
Progressive fibrosis of palmar fascia. etiololgy not known;

18. SAH due to posterior inferior cerebellar aneurysm
50%; tunneling between rectum or kin
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Headache - ataxia - bulbar dysfunction
Urethral stricture; pelvic of urethral trauma

19. conservative Tx of varicose veins
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

20. When goiter needs surgery
If any compressive symptoms eg. dysphagia
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 mesenteric ishemia; most SMA occlusion secondary to an embolism
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

21. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
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
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

22. What percent of anal abscess deveolop fisutula
Abd pain and tenderness; bloody diarrhoea or hematochezia
50%; tunneling between rectum or kin
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Nonunion and avascular necrosis; fx can block blood supply;

23. How to manage a patient with asystole
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fx displace >1mm - nonunion during followup - osteonecrosis
Epi and chest compressio for prolong period of time; atropine is given after epi;

24. How to confirm achiles tendon rupture
Meniscus injury; medial most common; pain/swelling; popping sensation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

25. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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 mesenteric ishemia; most SMA occlusion secondary to an embolism
CRPS
Progressive fibrosis of palmar fascia. etiololgy not known;

26. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
CRPS
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;

27. antibiotics of acute cholecystitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fx displace >1mm - nonunion during followup - osteonecrosis
Ampicillin sublactum - pipercillin - ceftriaxone and metro

28. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Compression stocking - weight reduction - leg elevation

29. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Amoxicillin-clavulanate

30. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
50%; tunneling between rectum or kin
15-40%; self limiting;doesn't require tx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

31. when patient with severe lung disease have C02 retention
Amoxicillin-clavulanate
Nonunion and avascular necrosis; fx can block blood supply;
24-48 hours of supportive therapy followed by cholecystectomy
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

32. Why ruq calcificaion is concerning
When urethral catherization is unsuccessful
Fx displace >1mm - nonunion during followup - osteonecrosis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population

33. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Tendons more likely
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation

34. What is most common lung injury after blunt chest trauma?
Brardycardia - HTN - resp depression
Tendons more likely
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

35. When patient can go back to sports after clavicle fx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports

36. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Seminomas
CRPS
Study showed no adverse effect; but they are contraindicated for PVD

37. complication displaced or communited distal radial fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Seminomas
Carpal tunnel syndrom

38. 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;
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Seminomas

39. acute colonic ischemia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

40. types of hip fracture
Meniscus injury; medial most common; pain/swelling; popping sensation
Mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
S2-S4

41. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Saline and silicone
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

42. Most common of sudden death due to steering wheel injury
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;

43. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Compression stocking - weight reduction - leg elevation
Even after ochiopexy risk of ochiopexy higher then general population

44. when scaphoid fx patient needs to be referred to orthopedic
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fx displace >1mm - nonunion during followup - osteonecrosis

45. What is hydrocele?
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Urethral stricture; pelvic of urethral trauma
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

46. scrotal trauma
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS
Next best step surgery; not ultrasound
SAH due to post communicating artery aneurysm;

47. pregnant patient with asymptomatic gall stones
Brardycardia - HTN - resp depression
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
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;

48. Why initial xrays are negative in scaphoid fx
24-48 hours of supportive therapy followed by cholecystectomy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

49. inhalation of hot air - steam - smoke in burn victim
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dm neuropathy; stocking glove pattern
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Supraglottic edema; low threshold for intubation

50. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx