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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. Dupuytren contracture
Patellar tendon tear; difficulty in extension
Progressive fibrosis of palmar fascia. etiololgy not known;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Urethral stricture; pelvic of urethral trauma

2. painless testicular mass in young male
Malignancy until proven otherwise
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
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
Elevated non seminomas

3. When goiter needs surgery
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If any compressive symptoms eg. dysphagia
Even after ochiopexy risk of ochiopexy higher then general population

4. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Brardycardia - HTN - resp depression
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pure motor stroke; limited neurological dysfunction

5. How to evaluate painless testicular swelling suspicious for cancer
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Urethral stricture; pelvic of urethral trauma
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Even after ochiopexy risk of ochiopexy higher then general population

6. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Study showed no adverse effect; but they are contraindicated for PVD
Seminomas
Saline and silicone

7. 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
24-48 hours of supportive therapy followed by cholecystectomy
Progressive fibrosis of palmar fascia. etiololgy not known;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

8. cremasteric reflex
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
If any compressive symptoms eg. dysphagia

9. Why right varicocele is more concerning?

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10. What is cushing's triad
Brardycardia - HTN - resp depression
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Check ET tube placement if correct needle decompresion
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;

11. popping sensation; rapid onset of knee effusion. athelet
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dumping syndrome; small and frequent meals; no simple sugar
ACL injury
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

12. suprapubic catheterization
When urethral catherization is unsuccessful
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
4-6 weeks for noncontact sports and longer time for contact sports
Tendons more likely

13. Why ruq calcificaion is concerning
If any compressive symptoms eg. dysphagia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

14. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

15. Can we use beta blocker for pvd?
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
Study showed no adverse effect; but they are contraindicated for PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pure motor stroke; limited neurological dysfunction

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Compression stocking - weight reduction - leg elevation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check ET tube placement if correct needle decompresion
Dm neuropathy; stocking glove pattern

17. Tx of proximal non metastatic rectal ca
Mammogram
Low anterior resection and radio; add chemo if node positive
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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

18. pregnant patient with asymptomatic gall stones
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole

19. How to manage a patient with asystole
Unilateral vocal cord paralysis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

20. What types of breast implants are available
Check ET tube placement if correct needle decompresion
Saline and silicone
Cystic scrotal fluid collection between parietal and visceral layers of testis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

21. acute colonic ischemia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS

22. how hyperventilation lowers ICP
10-12 months
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
50%; tunneling between rectum or kin

23. What percent of anal abscess deveolop fisutula
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
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
50%; tunneling between rectum or kin

24. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Saline and silicone
4-6 weeks for noncontact sports and longer time for contact sports
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

25. most common complication of acute cholecystitis
Klinefelter syndrome; 50 fold increase;
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

26. cat/dog bites
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Amoxicillin-clavulanate
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

27. management of gunshot wound
ACL injury
Even after ochiopexy risk of ochiopexy higher then general population
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
Retrograde ejaculation

28. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Patellar tendon tear; difficulty in extension
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate

29. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Epi and chest compressio for prolong period of time; atropine is given after epi;
SAH due to post communicating artery aneurysm;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

30. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
ACL injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Displaced ORIF ; nondisplaced sling immobilization

31. how ABI help dx of PVD
Malignancy until proven otherwise
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;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
24-48 hours of supportive therapy followed by cholecystectomy

32. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Check ET tube placement if correct needle decompresion
Low anterior resection and radio; add chemo if node positive

33. clavicle fx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Displaced ORIF ; nondisplaced sling immobilization
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

34. Complications of breast impant
Unilateral vocal cord paralysis
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

35. indication of ursodeoxycholic acid
When urethral catherization is unsuccessful
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
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

36. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Amoxicillin-clavulanate
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Subphrenic abscess or other abdominal abscesses; order US or CT
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. when scaphoid fx patient needs to be referred to orthopedic
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Retrograde ejaculation

38. cremasteric reflex test?
Less than 5mm
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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;
Dumping syndrome; small and frequent meals; no simple sugar

39. contraindication of urethral catheterization
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dm neuropathy; stocking glove pattern
Urethral stricture; pelvic of urethral trauma

40. menisci injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Displaced ORIF ; nondisplaced sling immobilization
Twisting force with the foot fixed on the ground seen in football and basketball games;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

41. What is prehn sign?
Ispilateral hypoglossal nerve injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;

42. most frequent complication of TURP
Saline and silicone
Retrograde ejaculation
Supraglottic edema; low threshold for intubation
If any compressive symptoms eg. dysphagia

43. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Epi and chest compressio for prolong period of time; atropine is given after epi;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

44. varicocele
Cystic scrotal fluid collection between parietal and visceral layers of testis
Meniscus injury; medial most common; pain/swelling; popping sensation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

45. What is hungry bone syndrome?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Subphrenic abscess or other abdominal abscesses; order US or CT
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

46. aspiration of breast cyst is nonbloody
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

47. beta hcg and AFP
Amoxicillin-clavulanate
Elevated non seminomas
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

48. Why initial xrays are negative in scaphoid fx
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

49. common complication of inadequate mx of scaphoid fx
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;
24-48 hours of supportive therapy followed by cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

50. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Seminomas
Malignancy until proven otherwise
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu