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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. diarrhoea after gastric bypass
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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;
Dumping syndrome; small and frequent meals; no simple sugar
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

2. common complication of inadequate mx of scaphoid fx
Compression stocking - weight reduction - leg elevation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Nonunion and avascular necrosis; fx can block blood supply;

3. 3 mo with groin bulge; bulge appears when child cries
Amoxicillin-clavulanate
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

4. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Klinefelter syndrome; 50 fold increase;
If patient ambulatory - surgery and pain control; if not nonop mx

5. types of hip fracture
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
S2-S4
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

6. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Study showed no adverse effect; but they are contraindicated for PVD
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Meniscus injury; medial most common; pain/swelling; popping sensation

7. pregnant patient with asymptomatic gall stones
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
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

8. cremasteric reflex
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
15-40%; self limiting;doesn't require tx

9. management of nondisplaced scaphoid fx
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
Saline and silicone
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

10. When to stop raloxifene before surgery
SAH due to post communicating artery aneurysm;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
When urethral catherization is unsuccessful

11. varicocele
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

12. Dupuytren contracture
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;
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

13. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Tendons more likely
Study showed no adverse effect; but they are contraindicated for PVD
Mammogram

14. clavicle fx
Tendons more likely
Brardycardia - HTN - resp depression
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Displaced ORIF ; nondisplaced sling immobilization

15. when patient with severe lung disease have C02 retention
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
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;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

16. Most common of sudden death due to steering wheel injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

17. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cystic scrotal fluid collection between parietal and visceral layers of testis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

18. How to dx ACL tear?
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
Malignancy until proven otherwise
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

19. when scaphoid fx patient needs to be referred to orthopedic
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pure motor stroke; limited neurological dysfunction

20. what size of ureteral stone for non op mx
Less than 5mm
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
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive

21. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Next best step surgery; not ultrasound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

22. What percent of anal abscess deveolop fisutula
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Less than 5mm
50%; tunneling between rectum or kin
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

23. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Less than 5mm
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
S2-S4

24. mx of stress fx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

25. dumping syndrome after gastrectomy
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
4-6 weeks for noncontact sports and longer time for contact sports
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

26. How varicocele causes testicular atrophy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS
Strok and traumatic brain injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

27. How to manage a patient with asystole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
When urethral catherization is unsuccessful

28. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population
Dm neuropathy; stocking glove pattern

29. What is cushing's triad
Progressive fibrosis of palmar fascia. etiololgy not known;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Brardycardia - HTN - resp depression
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

30. cremasteric reflex test?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
4-6 weeks for noncontact sports and longer time for contact sports
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

31. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If any compressive symptoms eg. dysphagia

32. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
50%; tunneling between rectum or kin
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

33. Tx of proximal non metastatic rectal ca
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Low anterior resection and radio; add chemo if node positive
Twisting force with the foot fixed on the ground seen in football and basketball games;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

34. xray finding of stress fx after 3-4w
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Malignancy until proven otherwise
24-48 hours of supportive therapy followed by cholecystectomy

35. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
10-12 months
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check ET tube placement if correct needle decompresion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

36. What types of breast implants are available
Saline and silicone
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Progressive fibrosis of palmar fascia. etiololgy not known;

37. first step for evaluation of testicular swelling
Displaced ORIF ; nondisplaced sling immobilization
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mammogram

38. What time frame required for bone remodeling
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
10-12 months
24-48 hours of supportive therapy followed by cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

39. managment of animal bite in hands
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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;
Patellar tendon tear; difficulty in extension

40. perioral numbness after parathyroidectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

41. management of stone 8-10mm
Compression stocking - weight reduction - leg elevation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
50%; tunneling between rectum or kin
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

42. ct scan; cystic lesion in head of pancreas; next step
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Study showed no adverse effect; but they are contraindicated for PVD
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

43. acalculus cholecystitis
Elderly and critically ill patients
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Displaced ORIF ; nondisplaced sling immobilization
Next best step surgery; not ultrasound

44. 27 yo with scrotal mass; warm tender testes feel like bag of worms
MAT; medial meniscus injury; ACL and Tibial colateral ligament
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

45. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy

46. first line of management of PVD
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;

47. When do we see complications due to hypophosphatemia
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;

48. anal sphincter tone
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
S2-S4
Brardycardia - HTN - resp depression

49. Why right varicocele is more concerning?

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50. diarrhoea 4-5 days after cholecystectomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Low anterior resection and radio; add chemo if node positive
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;