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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. most common complication of acute cholecystitis
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
Even after ochiopexy risk of ochiopexy higher then general population
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

2. Valgus and Varus tests
Study showed no adverse effect; but they are contraindicated for PVD
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Nonunion and avascular necrosis; fx can block blood supply;
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

3. mx of stress fx
Meniscus injury; medial most common; pain/swelling; popping sensation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

4. midline neck swelling moves with protrusion of tongue
Twisting force with the foot fixed on the ground seen in football and basketball games;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. anal sphincter tone
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Next best step surgery; not ultrasound
MAT; medial meniscus injury; ACL and Tibial colateral ligament
S2-S4

6. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Malignancy until proven otherwise
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

7. What is terrible triad
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

8. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
24-48 hours of supportive therapy followed by cholecystectomy

9. lacerated wound in palmer surface of hand. what structure is injured?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation
If any compressive symptoms eg. dysphagia
Tendons more likely

10. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Even after ochiopexy risk of ochiopexy higher then general population
SAH due to post communicating artery aneurysm;
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

11. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elderly and critically ill patients
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dm neuropathy; stocking glove pattern

12. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
SAH due to post communicating artery aneurysm;

13. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Carpal tunnel syndrom
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Epi and chest compressio for prolong period of time; atropine is given after epi;

14. popping sensation; rapid onset of knee effusion. athelet
ACL injury
CRPS
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

15. cremasteric reflex test?
Check ET tube placement if correct needle decompresion
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
15-40%; self limiting;doesn't require tx

16. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If any compressive symptoms eg. dysphagia
Supraglottic edema; low threshold for intubation
MAT; medial meniscus injury; ACL and Tibial colateral ligament

17. How to confirm achiles tendon rupture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

18. severe pain in leg after MVC
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Brardycardia - HTN - resp depression
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

19. suprapubic catheterization
S2-S4
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
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;

20. management of gunshot wound
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
Headache - ataxia - bulbar dysfunction
Dm neuropathy; stocking glove pattern
Even after ochiopexy risk of ochiopexy higher then general population

21. conservative Tx of varicose veins
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension
Compression stocking - weight reduction - leg elevation

22. indication of ursodeoxycholic 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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
10-12 months

23. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sphincter sparing surgery (local resection) - abdomnio perineal resection

24. Why right varicocele is more concerning?

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25. When to do surgery in undesceneded testis?
Malignancy until proven otherwise
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

26. Why varicocele more common in the left side
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

27. swelling and tenderness in anterior part of knee
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Patellar tendon tear; difficulty in extension

28. How mcmurray manuver perform
Even after ochiopexy risk of ochiopexy higher then general population
Low anterior resection and radio; add chemo if node positive
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

29. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

30. several knee pain after being tackled in football game
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Ispilateral hypoglossal nerve injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

31. first line of management of PVD
L5 to S2
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

32. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS
Next best step surgery; not ultrasound
Low anterior resection and radio; add chemo if node positive

33. How to differentiate ACL and meniscus injury
Amoxicillin-clavulanate
Ispilateral hypoglossal nerve injury
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
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

34. 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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Carpal tunnel syndrom

35. When do we see complications due to hypophosphatemia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Saline and silicone
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;
50%; tunneling between rectum or kin

36. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ACL injury

37. How to manage a patient with asystole
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
If any compressive symptoms eg. dysphagia
Epi and chest compressio for prolong period of time; atropine is given after epi;
SAH due to post communicating artery aneurysm;

38. beta hcg and AFP
Elevated non seminomas
15-40%; self limiting;doesn't require tx
ACL injury
Study showed no adverse effect; but they are contraindicated for PVD

39. What is most common lung injury after blunt chest trauma?
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization

40. xray finding of stress fx after 3-4w
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Klinefelter syndrome; 50 fold increase;

41. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

42. mangement of localized lymphadenopathy
Compression stocking - weight reduction - leg elevation
Next best step surgery; not ultrasound
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

43. What is hungry bone syndrome?
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Headache - ataxia - bulbar dysfunction

44. How varicocele causes testicular atrophy
Klinefelter syndrome; 50 fold increase;
Unilateral vocal cord paralysis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

45. most common fx when falling on outsretched hand
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
10-12 months
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

46. 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Supraglottic edema; low threshold for intubation
Compression stocking - weight reduction - leg elevation

47. 3 mo with groin bulge; bulge appears when child cries
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
Pure motor stroke; limited neurological dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

48. What is the complications of undescended testis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Even after ochiopexy risk of ochiopexy higher then general population
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
ACL injury

49. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Dm neuropathy; stocking glove pattern
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

50. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Pure motor stroke; limited neurological dysfunction
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
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