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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. pregnant patient with asymptomatic gall stones
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
SAH due to post communicating artery aneurysm;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Headache - ataxia - bulbar dysfunction

2. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
When urethral catherization is unsuccessful

3. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Low anterior resection and radio; add chemo if node positive
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

4. indication of ursodeoxycholic acid
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

5. 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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Unilateral vocal cord paralysis

6. antibiotics of acute cholecystitis
Supraglottic edema; low threshold for intubation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ampicillin sublactum - pipercillin - ceftriaxone and metro
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

7. complications of TPN
ACL injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Low anterior resection and radio; add chemo if node positive
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

8. characteristics of ureteral stone?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

9. ipsilateral deviation of tongue upon protrusion
Unilateral vocal cord paralysis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Ispilateral hypoglossal nerve injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

10. Patient underwent CABG; postoperatively drowsy. most likely cause?
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Patellar tendon tear; difficulty in extension
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

11. Tx of proximal non metastatic rectal ca
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Low anterior resection and radio; add chemo if node positive
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Strok and traumatic brain injury

12. How to dx ACL tear?
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
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
Retrograde ejaculation

13. managment of animal bite in hands
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Mammogram
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

14. Can we use beta blocker for pvd?
Klinefelter syndrome; 50 fold increase;
Study showed no adverse effect; but they are contraindicated for PVD
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
Retrograde ejaculation

15. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dumping syndrome; small and frequent meals; no simple sugar
Cystic scrotal fluid collection between parietal and visceral layers of testis

16. SOB - confusion - petechial rash after trauma - fracture
Even after ochiopexy risk of ochiopexy higher then general population
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Brardycardia - HTN - resp depression
Fx displace >1mm - nonunion during followup - osteonecrosis

17. How to differentiate ACL and meniscus injury
Mammogram
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

18. types of hip fracture
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
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

19. cremasteric reflex
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
15-40%; self limiting;doesn't require tx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

20. 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
Headache - ataxia - bulbar dysfunction
Unilateral vocal cord paralysis

21. prostate enlarged - nontender - no nodularity - elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Abd pain and tenderness; bloody diarrhoea or hematochezia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

22. most common complication of acute cholecystitis
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Nonunion and avascular necrosis; fx can block blood supply;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

23. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
Strok and traumatic brain injury
Dm neuropathy; stocking glove pattern

24. What are the common injuries from lightning?
If patient ambulatory - surgery and pain control; if not nonop mx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

25. most frequent complication of TURP
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

26. What is the complications of undescended testis
Klinefelter syndrome; 50 fold increase;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Dumping syndrome; small and frequent meals; no simple sugar
Even after ochiopexy risk of ochiopexy higher then general population

27. popping sensation; rapid onset of knee effusion. athelet
Fx displace >1mm - nonunion during followup - osteonecrosis
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Study showed no adverse effect; but they are contraindicated for PVD

28. beta hcg and AFP
Epi and chest compressio for prolong period of time; atropine is given after epi;
Meniscus injury; medial most common; pain/swelling; popping sensation
Elevated non seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;

29. how ABI help dx of PVD
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Tendons more likely

30. differential of ultrasound finding of breast mass
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
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
Patellar tendon tear; difficulty in extension
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

31. acalculus cholecystitis
15-40%; self limiting;doesn't require tx
ACL injury
Elderly and critically ill patients
50%; tunneling between rectum or kin

32. Incidence of AF in CABG patient

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33. 3 mo with groin bulge; bulge appears when child cries
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Next best step surgery; not ultrasound
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

34. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
CRPS
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

35. mx of stress fx
Low anterior resection and radio; add chemo if node positive
Elevated non seminomas
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

36. complication displaced or communited distal radial fx
4-6 weeks for noncontact sports and longer time for contact sports
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Carpal tunnel syndrom
Displaced ORIF ; nondisplaced sling immobilization

37. When to do surgery in undesceneded testis?
24-48 hours of supportive therapy followed by cholecystectomy
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Strok and traumatic brain injury

38. scrotal trauma
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
Elderly and critically ill patients
Next best step surgery; not ultrasound
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;

39. suprapubic catheterization
When urethral catherization is unsuccessful
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
10-12 months

40. What is hydrocele?
Epi and chest compressio for prolong period of time; atropine is given after epi;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cystic scrotal fluid collection between parietal and visceral layers of testis
10-12 months

41. varicocele
Displaced ORIF ; nondisplaced sling immobilization
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

42. How to manage a patient with asystole
Displaced ORIF ; nondisplaced sling immobilization
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT

43. how hyperventilation lowers ICP
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;
Displaced ORIF ; nondisplaced sling immobilization
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

44. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

45. painless testicular mass in young male
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

46. clavicle fx
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Progressive fibrosis of palmar fascia. etiololgy not known;
Displaced ORIF ; nondisplaced sling immobilization

47. When to stop raloxifene before surgery
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Saline and silicone

48. DD of acute scrotal pain
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

49. Valgus and Varus tests
4-6 weeks for noncontact sports and longer time for contact sports
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

50. xray finding of stress fx after 3-4w
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Low anterior resection and radio; add chemo if node positive
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)