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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. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
15-40%; self limiting;doesn't require tx
Dumping syndrome; small and frequent meals; no simple sugar
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

2. Why ruq calcificaion is concerning
S2-S4
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective 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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

3. first step for evaluation of testicular swelling
Urethral stricture; pelvic of urethral trauma
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Seminomas
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

4. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
50%; tunneling between rectum or kin
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Elevated non seminomas

5. transrectal prostate biopsy
Brardycardia - HTN - resp depression
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

6. what size of ureteral stone for non op mx
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months
Mammogram
Less than 5mm

7. lacunar stroke
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
Pure motor stroke; limited neurological dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

8. What is prehn sign?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Study showed no adverse effect; but they are contraindicated for PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

9. What percent of anal abscess deveolop fisutula
CRPS
50%; tunneling between rectum or kin
Saline and silicone
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

10. aspiration of breast cyst is nonbloody
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Elevated non seminomas
Supraglottic edema; low threshold for intubation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

11. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Displaced ORIF ; nondisplaced sling immobilization
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Saline and silicone

12. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
S2-S4
Supraglottic edema; low threshold for intubation
Patellar tendon tear; difficulty in extension

13. When to do surgery in undesceneded testis?
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

14. What are the common injuries from lightning?
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;
10-12 months
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
When urethral catherization is unsuccessful

15. xray finding of stress fx after 3-4w
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Progressive fibrosis of palmar fascia. etiololgy not known;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

16. painless testicular mass in young male
Pure motor stroke; limited neurological dysfunction
Compression stocking - weight reduction - leg elevation
S2-S4
Malignancy until proven otherwise

17. When goiter needs surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If any compressive symptoms eg. dysphagia
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

18. when scaphoid fx patient needs to be referred to orthopedic
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Fx displace >1mm - nonunion during followup - osteonecrosis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

19. lacerated wound in palmer surface of hand. what structure is injured?
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Tendons more likely

20. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
10-12 months
Patellar tendon tear; difficulty in extension

21. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Compression stocking - weight reduction - leg elevation

22. tx distal rectal ca
Compression stocking - weight reduction - leg elevation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

23. scrotal trauma
Next best step surgery; not ultrasound
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

24. indication of ursodeoxycholic acid
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

25. How to manage a patient with asystole
Klinefelter syndrome; 50 fold increase;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

26. ipsilateral deviation of tongue upon protrusion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ispilateral hypoglossal nerve injury
Carpal tunnel syndrom
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. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Malignancy until proven otherwise
Twisting force with the foot fixed on the ground seen in football and basketball games;

28. several knee pain after being tackled in football game
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
4-6 weeks for noncontact sports and longer time for contact sports
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

29. contraindication of urethral catheterization
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;
Seminomas
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Urethral stricture; pelvic of urethral trauma

30. Most common of sudden death due to steering wheel injury
Dm neuropathy; stocking glove pattern
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

31. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Progressive fibrosis of palmar fascia. etiololgy not known;
50%; tunneling between rectum or kin
Less than 5mm

32. inhalation of hot air - steam - smoke in burn victim
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
Displaced ORIF ; nondisplaced sling immobilization
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
Supraglottic edema; low threshold for intubation

33. most common complication of acute cholecystitis
Progressive fibrosis of palmar fascia. etiololgy not known;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

34. How to confirm achiles tendon rupture
Check ET tube placement if correct needle decompresion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

35. first line of management of PVD
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
CRPS

36. aspiration of breast cyst is bloody
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Patellar tendon tear; difficulty in extension
Mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

37. characteristics of ureteral stone?
Amoxicillin-clavulanate
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
Retrograde ejaculation

38. When patient can go back to sports after clavicle fx
Headache - ataxia - bulbar dysfunction
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
4-6 weeks for noncontact sports and longer time for contact sports
Check ET tube placement if correct needle decompresion

39. Indication for bariatric surgery in obese patients
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
15-40%; self limiting;doesn't require tx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

40. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;
ACL injury
Next best step surgery; not ultrasound

41. How to evaluate painless testicular swelling suspicious for cancer
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
Saline and silicone
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

42. How mcmurray manuver perform
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Elderly and critically ill patients
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

43. types of hip fracture
4-6 weeks for noncontact sports and longer time for contact sports
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

44. acalculus cholecystitis
10-12 months
Tendons more likely
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elderly and critically ill patients

45. antibiotics of acute cholecystitis
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
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.
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

46. mangement of localized lymphadenopathy
15-40%; self limiting;doesn't require tx
Compression stocking - weight reduction - leg elevation
Ispilateral hypoglossal nerve injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

47. What is terrible triad
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4-6 weeks for noncontact sports and longer time for contact sports

48. when patient with severe lung disease have C02 retention
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

49. What time frame required for bone remodeling
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Strok and traumatic brain injury
10-12 months
Fx displace >1mm - nonunion during followup - osteonecrosis

50. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Unilateral vocal cord paralysis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
SAH due to post communicating artery aneurysm;