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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. What is hungry bone syndrome?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Malignancy until proven otherwise
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. surgery for acute cholecystities
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Low anterior resection and radio; add chemo if node positive
24-48 hours of supportive therapy followed by cholecystectomy
Next best step surgery; not ultrasound

3. What is the complications of undescended testis
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Even after ochiopexy risk of ochiopexy higher then general population
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

4. What types of breast implants are available
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
Saline and silicone
Study showed no adverse effect; but they are contraindicated for PVD
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

5. painless testicular mass in young male
Pure motor stroke; limited neurological dysfunction
Malignancy until proven otherwise
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

6. anal sphincter tone
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
S2-S4

7. Dupuytren contracture
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
Progressive fibrosis of palmar fascia. etiololgy not known;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

8. Most common of sudden death due to steering wheel injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Meniscus injury; medial most common; pain/swelling; popping sensation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

9. Tx of pulmonary contusion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mammogram
Meniscus injury; medial most common; pain/swelling; popping sensation

10. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

11. Why ruq calcificaion is concerning
Fx displace >1mm - nonunion during followup - osteonecrosis
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Urethral stricture; pelvic of urethral trauma

12. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Even after ochiopexy risk of ochiopexy higher then general population
S2-S4
24-48 hours of supportive therapy followed by cholecystectomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

13. 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.
Elderly and critically ill patients
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If patient ambulatory - surgery and pain control; if not nonop mx

14. When to stop raloxifene before surgery
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
ACL injury
Seminomas
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

15. What is hydrocele?
Headache - ataxia - bulbar dysfunction
Study showed no adverse effect; but they are contraindicated for PVD
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

16. antibiotics of acute cholecystitis
Study showed no adverse effect; but they are contraindicated for PVD
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Ampicillin sublactum - pipercillin - ceftriaxone and metro

17. What is cushing's triad
Seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Brardycardia - HTN - resp depression
Subphrenic abscess or other abdominal abscesses; order US or CT

18. 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
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

19. What is the strongest risk factor for male breast cancer
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Klinefelter syndrome; 50 fold increase;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. when patient with severe lung disease have C02 retention
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Headache - ataxia - bulbar dysfunction
Patellar tendon tear; difficulty in extension

21. When patient can go back to sports after clavicle fx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4-6 weeks for noncontact sports and longer time for contact sports
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

22. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
SAH due to post communicating artery aneurysm;
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

23. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If patient ambulatory - surgery and pain control; if not nonop mx
Saline and silicone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

24. beta HCG
Seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

25. clavicle fx
Klinefelter syndrome; 50 fold increase;
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
Displaced ORIF ; nondisplaced sling immobilization
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

26. transrectal prostate biopsy
When urethral catherization is unsuccessful
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Check ET tube placement if correct needle decompresion
Compression stocking - weight reduction - leg elevation

27. Why right varicocele is more concerning?

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28. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
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

29. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Headache - ataxia - bulbar dysfunction
4-6 weeks for noncontact sports and longer time for contact sports

30. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Saline and silicone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dm neuropathy; stocking glove pattern
Abd pain and tenderness; bloody diarrhoea or hematochezia

31. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Dumping syndrome; small and frequent meals; no simple sugar
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

32. conservative Tx of varicose veins
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Compression stocking - weight reduction - leg elevation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
SAH due to post communicating artery aneurysm;

33. when scaphoid fx patient needs to be referred to orthopedic
Meniscus injury; medial most common; pain/swelling; popping sensation
When urethral catherization is unsuccessful
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;
Fx displace >1mm - nonunion during followup - osteonecrosis

34. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
Dm neuropathy; stocking glove pattern
Saline and silicone

35. Why initial xrays are negative in scaphoid fx
Less than 5mm
Brardycardia - HTN - resp depression
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

36. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Saline and silicone
CRPS
Patellar tendon tear; difficulty in extension

37. How to confirm achiles tendon rupture
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

38. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

39. ipsilateral deviation of tongue upon protrusion
24-48 hours of supportive therapy followed by cholecystectomy
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
Ispilateral hypoglossal nerve injury

40. differential of ultrasound finding of breast mass
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
10-12 months

41. diarrhoea 4-5 days after cholecystectomy
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

42. prostate enlarged - nontender - no nodularity - elevated PSA
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

43. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

44. common complication of inadequate mx of scaphoid fx
Malignancy until proven otherwise
Nonunion and avascular necrosis; fx can block blood supply;
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

45. What is the contraindication of hyperventilation in inc ICP
Ispilateral hypoglossal nerve injury
Strok and traumatic brain injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Subphrenic abscess or other abdominal abscesses; order US or CT
Next best step surgery; not ultrasound
Check ET tube placement if correct needle decompresion
Patellar tendon tear; difficulty in extension

47. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

48. Complications of breast impant
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

49. menisci injury
10-12 months
Twisting force with the foot fixed on the ground seen in football and basketball games;
Unilateral vocal cord paralysis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

50. first line of management of PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Low anterior resection and radio; add chemo if node positive