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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. suprapubic catheterization
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
When urethral catherization is unsuccessful

2. management of nondisplaced scaphoid fx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dumping syndrome; small and frequent meals; no simple sugar
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

3. 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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Tendons more likely
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

4. anal sphincter tone
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
S2-S4
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

5. pregnant patient with asymptomatic gall stones
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Headache - ataxia - bulbar dysfunction
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

6. What is most common lung injury after blunt chest trauma?
Headache - ataxia - bulbar dysfunction
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
Strok and traumatic brain injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

7. DD of acute scrotal pain
Retrograde ejaculation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

8. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

9. What percent of anal abscess deveolop fisutula
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
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
50%; tunneling between rectum or kin

10. lacunar stroke
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pure motor stroke; limited neurological dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

11. How to dx ACL tear?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevated non seminomas
Patellar tendon tear; difficulty in extension
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

12. How to confirm achiles tendon rupture
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;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
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

13. Why varicocele more common in the left side
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
10-12 months
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

14. When to do surgery in undesceneded testis?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

15. How to differentiate communicative and non-communicative hydrocele
Study showed no adverse effect; but they are contraindicated for PVD
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Urethral stricture; pelvic of urethral trauma

16. What time frame required for bone remodeling
10-12 months
Study showed no adverse effect; but they are contraindicated for PVD
Compression stocking - weight reduction - leg elevation
Headache - ataxia - bulbar dysfunction

17. cremasteric reflex test?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dumping syndrome; small and frequent meals; no simple sugar

18. indication of ursodeoxycholic acid
Supraglottic edema; low threshold for intubation
Retrograde ejaculation
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
Urethral stricture; pelvic of urethral trauma

19. What is hungry bone syndrome?
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
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
Strok and traumatic brain injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

20. scrotal trauma
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Next best step surgery; not ultrasound
Seminomas

21. transrectal prostate biopsy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

22. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
4-6 weeks for noncontact sports and longer time for contact sports
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;

23. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

24. tx distal rectal ca
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Less than 5mm
When urethral catherization is unsuccessful

25. Complications of breast impant
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Progressive fibrosis of palmar fascia. etiololgy not known;

26. diarrhoea 4-5 days after cholecystectomy
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Patellar tendon tear; difficulty in extension

27. characteristics of ureteral stone?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

28. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

29. management of stone 8-10mm
Malignancy until proven otherwise
<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
Ispilateral hypoglossal nerve injury

30. when scaphoid fx patient needs to be referred to orthopedic
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Fx displace >1mm - nonunion during followup - osteonecrosis

31. surgery for acute cholecystities
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation
Check ET tube placement if correct needle decompresion
24-48 hours of supportive therapy followed by cholecystectomy

32. dumping syndrome after gastrectomy
Tendons more likely
S2-S4
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

33. What is terrible triad
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
Patellar tendon tear; difficulty in extension
Cystic scrotal fluid collection between parietal and visceral layers of testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament

34. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
S2-S4
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Displaced ORIF ; nondisplaced sling immobilization

35. 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.
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Study showed no adverse effect; but they are contraindicated for PVD
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

36. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

37. common complication of inadequate mx of scaphoid fx
Supraglottic edema; low threshold for intubation
Nonunion and avascular necrosis; fx can block blood supply;
If any compressive symptoms eg. dysphagia
Dumping syndrome; small and frequent meals; no simple sugar

38. How to manage a patient with asystole
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Epi and chest compressio for prolong period of time; atropine is given after epi;
Ispilateral hypoglossal nerve injury

39. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Dm neuropathy; stocking glove pattern
Twisting force with the foot fixed on the ground seen in football and basketball games;

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
SAH due to post communicating artery aneurysm;

41. 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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

42. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Next best step surgery; not ultrasound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. acute colonic ischemia
4-6 weeks for noncontact sports and longer time for contact sports
Abd pain and tenderness; bloody diarrhoea or hematochezia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

44. Why right varicocele is more concerning?

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45. What is prehn sign?
Strok and traumatic brain injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Pure motor stroke; limited neurological dysfunction

46. diarrhoea after gastric bypass
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Strok and traumatic brain injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dumping syndrome; small and frequent meals; no simple sugar

47. 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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Urethral stricture; pelvic of urethral trauma

48. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Carpal tunnel syndrom

49. cremasteric reflex
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

50. complications of TPN
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If patient ambulatory - surgery and pain control; if not nonop mx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation