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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. popping sensation; rapid onset of knee effusion. athelet
Supraglottic edema; low threshold for intubation
Compression stocking - weight reduction - leg elevation
ACL injury
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

2. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Cystic scrotal fluid collection between parietal and visceral layers of testis
Carpal tunnel syndrom
Progressive fibrosis of palmar fascia. etiololgy not known;

3. scrotal trauma
Cystic scrotal fluid collection between parietal and visceral layers of testis
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Next best step surgery; not ultrasound

4. lacerated wound in palmer surface of hand. what structure is injured?
Seminomas
Tendons more likely
Patellar tendon tear; difficulty in extension
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

5. complication displaced or communited distal radial fx
Even after ochiopexy risk of ochiopexy higher then general population
Carpal tunnel syndrom
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Urethral stricture; pelvic of urethral trauma

6. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Brardycardia - HTN - resp depression
If patient ambulatory - surgery and pain control; if not nonop mx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

7. What is hungry bone syndrome?
Less than 5mm
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

8. ct scan; cystic lesion in head of pancreas; next step
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
S2-S4

9. Valgus and Varus tests
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

10. Dupuytren contracture
L5 to S2
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Progressive fibrosis of palmar fascia. etiololgy not known;

11. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

12. management of hip fracture
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If patient ambulatory - surgery and pain control; if not nonop mx
Fx displace >1mm - nonunion during followup - osteonecrosis
Abd pain and tenderness; bloody diarrhoea or hematochezia

13. When do we see complications due to hypophosphatemia
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;
Pure motor stroke; limited neurological dysfunction
24-48 hours of supportive therapy followed by cholecystectomy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

14. swelling and tenderness in anterior part of knee
Seminomas
Patellar tendon tear; difficulty in extension
Subphrenic abscess or other abdominal abscesses; order US or CT
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

15. stress fx
Subphrenic abscess or other abdominal abscesses; order US or CT
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

16. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Brardycardia - HTN - resp depression
Study showed no adverse effect; but they are contraindicated for PVD
Elevated non seminomas

17. aspiration of breast cyst is bloody
Mammogram
When urethral catherization is unsuccessful
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity

18. Why varicocele more common in the left side
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

19. SOB - confusion - petechial rash after trauma - fracture
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

20. Indication for bariatric surgery in obese patients
Ispilateral hypoglossal nerve injury
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

21. What is cushing's triad
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Brardycardia - HTN - resp depression
Ampicillin sublactum - pipercillin - ceftriaxone and metro

22. What types of breast implants are available
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Saline and silicone
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

23. cremasteric reflex test?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

24. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

25. cat/dog bites
Amoxicillin-clavulanate
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
4-6 weeks for noncontact sports and longer time for contact sports
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

26. Patient underwent CABG; postoperatively drowsy. most likely cause?
Strok and traumatic brain injury
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
Retrograde ejaculation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

27. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Pure motor stroke; limited neurological dysfunction

28. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;

29. complications of TPN
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Urethral stricture; pelvic of urethral trauma
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

30. How to manage obesity
Klinefelter syndrome; 50 fold increase;
Strok and traumatic brain injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

31. How to confirm dx of compartment syndrom
If any compressive symptoms eg. dysphagia
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

32. varicocele
Saline and silicone
ACL injury
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

33. how hyperventilation lowers ICP
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Tendons more likely

34. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
When urethral catherization is unsuccessful

35. perioral numbness after parathyroidectomy
50%; tunneling between rectum or kin
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Amoxicillin-clavulanate

36. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
SAH due to post communicating artery aneurysm;
Fx displace >1mm - nonunion during followup - osteonecrosis

37. most common fx when falling on outsretched hand
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Headache - ataxia - bulbar dysfunction
Low anterior resection and radio; add chemo if node positive
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

38. diarrhoea 4-5 days after cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abd pain and tenderness; bloody diarrhoea or hematochezia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

39. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Amoxicillin-clavulanate
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dm neuropathy; stocking glove pattern
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

40. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

41. How to dx ACL tear?
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

42. acalculus cholecystitis
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
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Elderly and critically ill patients

43. dumping syndrome after gastrectomy
Compression stocking - weight reduction - leg elevation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Urethral stricture; pelvic of urethral trauma

44. How to differentiate ACL and meniscus injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pure motor stroke; limited neurological dysfunction
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
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

45. recurrent laryngeal nerve injury
Amoxicillin-clavulanate
Unilateral vocal cord paralysis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

46. How to manage a patient with asystole
Less than 5mm
Epi and chest compressio for prolong period of time; atropine is given after epi;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

47. What is most common lung injury after blunt chest trauma?
Progressive fibrosis of palmar fascia. etiololgy not known;
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

48. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Patellar tendon tear; difficulty in extension

49. pregnant patient with asymptomatic gall stones
50%; tunneling between rectum or kin
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

50. What is terrible triad
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
Patellar tendon tear; difficulty in extension
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction