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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
Meniscus injury; medial most common; pain/swelling; popping sensation
Seminomas
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

2. surgery for acute cholecystities
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
24-48 hours of supportive therapy followed by cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization
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

3. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
S2-S4
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
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

4. How to evaluate painless testicular swelling suspicious for cancer
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

5. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
If any compressive symptoms eg. dysphagia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Headache - ataxia - bulbar dysfunction

6. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation
S2-S4
When urethral catherization is unsuccessful

7. characteristics of ureteral stone?
Klinefelter syndrome; 50 fold increase;
Check ET tube placement if correct needle decompresion
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

8. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Tendons more likely
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

9. cat/dog bites
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Amoxicillin-clavulanate
Subphrenic abscess or other abdominal abscesses; order US or CT

10. acalculus cholecystitis
CRPS
Elderly and critically ill patients
Fx displace >1mm - nonunion during followup - osteonecrosis
Cystic scrotal fluid collection between parietal and visceral layers of testis

11. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Carpal tunnel syndrom
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Saline and silicone

12. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

13. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
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

14. painless testicular mass in young male
Fx displace >1mm - nonunion during followup - osteonecrosis
Malignancy until proven otherwise
Mammogram
Elderly and critically ill patients

15. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
ACL injury
4-6 weeks for noncontact sports and longer time for contact sports

16. xray finding of stress fx after 3-4w
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elderly and critically ill patients
Carpal tunnel syndrom

17. management of stone 8-10mm
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Nonunion and avascular necrosis; fx can block blood supply;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

18. What is cushing's triad
Dumping syndrome; small and frequent meals; no simple sugar
Klinefelter syndrome; 50 fold increase;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Brardycardia - HTN - resp depression

19. What is hungry bone syndrome?
24-48 hours of supportive therapy followed by cholecystectomy
If any compressive symptoms eg. dysphagia
Elderly and critically ill patients
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

20. When to do surgery in undesceneded testis?
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

21. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
24-48 hours of supportive therapy followed by cholecystectomy
L5 to S2
Sphincter sparing surgery (local resection) - abdomnio perineal resection

22. DD of acute scrotal pain
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Patellar tendon tear; difficulty in extension
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

23. varicocele
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Epi and chest compressio for prolong period of time; atropine is given after epi;
Nonunion and avascular necrosis; fx can block blood supply;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

24. most frequent complication of TURP
Retrograde ejaculation
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
4-6 weeks for noncontact sports and longer time for contact sports
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

25. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT
Compression stocking - weight reduction - leg elevation
Twisting force with the foot fixed on the ground seen in football and basketball games;

26. When do we see complications due to hypophosphatemia
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;
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
Pure motor stroke; limited neurological dysfunction

27. midline neck swelling moves with protrusion of tongue
Elderly and critically ill patients
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Check ET tube placement if correct needle decompresion

28. contraindication of urethral catheterization
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
S2-S4
Urethral stricture; pelvic of urethral trauma

29. what size of ureteral stone for non op mx
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
Less than 5mm
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

30. Can we use beta blocker for pvd?
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Study showed no adverse effect; but they are contraindicated for PVD
Dm neuropathy; stocking glove pattern
4-6 weeks for noncontact sports and longer time for contact sports

31. stress fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Strok and traumatic brain injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

32. diarrhoea 4-5 days after cholecystectomy
Study showed no adverse effect; but they are contraindicated for PVD
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
Carpal tunnel syndrom
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

33. suprapubic catheterization
Cystic scrotal fluid collection between parietal and visceral layers of testis
When urethral catherization is unsuccessful
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

34. Most common of sudden death due to steering wheel injury
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
Dm neuropathy; stocking glove pattern
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

35. Why varicocele more common in the left side
Dumping syndrome; small and frequent meals; no simple sugar
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

36. differential of ultrasound finding of breast mass
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. What is terrible triad
Retrograde ejaculation
Abd pain and tenderness; bloody diarrhoea or hematochezia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;

38. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Study showed no adverse effect; but they are contraindicated for PVD
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

39. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Twisting force with the foot fixed on the ground seen in football and basketball games;
Meniscus injury; medial most common; pain/swelling; popping sensation
50%; tunneling between rectum or kin

40. management of gunshot wound
Dumping syndrome; small and frequent meals; no simple sugar
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check ET tube placement if correct needle decompresion

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Strok and traumatic brain injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Meniscus injury; medial most common; pain/swelling; popping sensation

42. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

43. Incidence of AF in CABG patient

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44. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

45. What is prehn sign?
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
When urethral catherization is unsuccessful

46. Why ruq calcificaion is concerning
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

47. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Tendons more likely
S2-S4
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

48. inhalation of hot air - steam - smoke in burn victim
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Supraglottic edema; low threshold for intubation
Amoxicillin-clavulanate

49. aspiration of breast cyst is bloody
Mammogram
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. dorsiflexion and planter flexion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
L5 to S2
Patellar tendon tear; difficulty in extension
50%; tunneling between rectum or kin