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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. ct scan; cystic lesion in head of pancreas; next step
Check ET tube placement if correct needle decompresion
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

2. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

3. 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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pure motor stroke; limited neurological dysfunction
Supraglottic edema; low threshold for intubation

4. 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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

5. common complication of inadequate mx of scaphoid fx
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
Nonunion and avascular necrosis; fx can block blood supply;
Displaced ORIF ; nondisplaced sling immobilization
Saline and silicone

6. when scaphoid fx patient needs to be referred to orthopedic
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Saline and silicone
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
Fx displace >1mm - nonunion during followup - osteonecrosis

7. When do we see complications due to hypophosphatemia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Study showed no adverse effect; but they are contraindicated for PVD
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;

8. What are the common injuries from lightning?
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Headache - ataxia - bulbar dysfunction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elderly and critically ill patients

9. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Urethral stricture; pelvic of urethral trauma
Check ET tube placement if correct needle decompresion
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Carpal tunnel syndrom

10. Complications of breast impant
Elderly and critically ill patients
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pure motor stroke; limited neurological dysfunction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

11. when patient with severe lung disease have C02 retention
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
SAH due to post communicating artery aneurysm;
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

12. perioral numbness after parathyroidectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Pure motor stroke; limited neurological dysfunction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

13. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cystic scrotal fluid collection between parietal and visceral layers of testis
Amoxicillin-clavulanate
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

14. What is hungry bone syndrome?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If patient ambulatory - surgery and pain control; if not nonop mx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

15. recurrent laryngeal nerve injury
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis

16. What is most common lung injury after blunt chest trauma?
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

17. ipsilateral deviation of tongue upon protrusion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Ispilateral hypoglossal nerve 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
Even after ochiopexy risk of ochiopexy higher then general population

18. several knee pain after being tackled in football game
CRPS
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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. beta HCG
Seminomas
Low anterior resection and radio; add chemo if node positive
Patellar tendon tear; difficulty in extension
4-6 weeks for noncontact sports and longer time for contact sports

20. managment of animal bite in hands
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;
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Abd pain and tenderness; bloody diarrhoea or hematochezia

21. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
24-48 hours of supportive therapy followed by cholecystectomy
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

22. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If any compressive symptoms eg. dysphagia
Pure motor stroke; limited neurological dysfunction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

23. Indication for bariatric surgery in obese patients
S2-S4
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
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;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

24. What is the strongest risk factor for male breast cancer
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Klinefelter syndrome; 50 fold increase;

25. cat/dog bites
Amoxicillin-clavulanate
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

26. complications of TPN
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

27. How to manage a patient with asystole
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Check ET tube placement if correct needle decompresion

28. Why initial xrays are negative in scaphoid fx
Tendons more likely
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

29. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Next best step surgery; not ultrasound
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

30. Why varicocele more common in the left side
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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 injury; medial most common; pain/swelling; popping sensation

31. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
When urethral catherization is unsuccessful
Amoxicillin-clavulanate
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

32. How to confirm dx of compartment syndrom
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

33. acalculus cholecystitis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Meniscus injury; medial most common; pain/swelling; popping sensation
Compression stocking - weight reduction - leg elevation
Elderly and critically ill patients

34. How to confirm achiles tendon rupture
Elevated non seminomas
Elderly and critically ill patients
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

35. Can we use beta blocker for pvd?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dm neuropathy; stocking glove pattern
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
Study showed no adverse effect; but they are contraindicated for PVD

36. sudden onset of postoperative hyperglycemia when patient on TPN
Displaced ORIF ; nondisplaced sling immobilization
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elderly and critically ill patients
Pure motor stroke; limited neurological dysfunction

37. What is the complications of undescended testis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Even after ochiopexy risk of ochiopexy higher then general population
Elderly and critically ill patients
Next best step surgery; not ultrasound

38. Why right varicocele is more concerning?

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39. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Cystic scrotal fluid collection between parietal and visceral layers of testis

40. characteristics of ureteral stone?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Headache - ataxia - bulbar dysfunction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

42. How to dx ACL tear?
Progressive fibrosis of palmar fascia. etiololgy not known;
S2-S4
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

43. What types of breast implants are available
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Saline and silicone
Seminomas
Retrograde ejaculation

44. management of gunshot wound
Dumping syndrome; small and frequent meals; no simple sugar
Carpal tunnel syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

45. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevated non seminomas
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

46. How to perform lachman test
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

47. tx distal rectal ca
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

48. management of nondisplaced scaphoid fx
Brardycardia - HTN - resp depression
Cystic scrotal fluid collection between parietal and visceral layers of testis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

49. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pure motor stroke; limited neurological dysfunction
Low anterior resection and radio; add chemo if node positive

50. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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