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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 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

2. complication displaced or communited distal radial fx
Progressive fibrosis of palmar fascia. etiololgy not known;
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

3. suprapubic catheterization
Brardycardia - HTN - resp depression
When urethral catherization is unsuccessful
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

4. midline neck swelling moves with protrusion of tongue
Tendons more likely
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. acute colonic ischemia
CRPS
Abd pain and tenderness; bloody diarrhoea or hematochezia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;

6. Complications of breast impant
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dm neuropathy; stocking glove pattern
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Compression stocking - weight reduction - leg elevation

7. Why ruq calcificaion is concerning
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

8. indication of ursodeoxycholic acid
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Patellar tendon tear; difficulty in extension
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

9. cremasteric reflex test?
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
S2-S4
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

10. How to differentiate ACL and meniscus injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
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
Headache - ataxia - bulbar dysfunction

11. How to perform lachman test
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

12. 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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

13. acalculus cholecystitis
Malignancy until proven otherwise
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dm neuropathy; stocking glove pattern
Elderly and critically ill patients

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

15. How to evaluate painless testicular swelling suspicious for cancer
Next best step surgery; not ultrasound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

16. What percent of anal abscess deveolop fisutula
Urethral stricture; pelvic of urethral trauma
Supraglottic edema; low threshold for intubation
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
50%; tunneling between rectum or kin

17. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Seminomas
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

18. swelling and tenderness in anterior part of knee
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Patellar tendon tear; difficulty in extension
Increased size during the day and valsalva means it is communicated with peritoneal cavity

19. cremasteric reflex
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

20. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

21. Most common of sudden death due to steering wheel injury
Displaced ORIF ; nondisplaced sling immobilization
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

22. When to stop raloxifene before surgery
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

23. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

24. What is the complications of undescended testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Next best step surgery; not ultrasound
Even after ochiopexy risk of ochiopexy higher then general population
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

25. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

26. Tx of proximal non metastatic rectal ca
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Low anterior resection and radio; add chemo if node positive
Less than 5mm
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

27. aspiration of breast cyst is nonbloody
Saline and silicone
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
10-12 months

28. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
SAH due to post communicating artery aneurysm;

29. Indication for bariatric surgery in obese patients
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;

30. What is most common lung injury after blunt chest trauma?
Seminomas
Displaced ORIF ; nondisplaced sling immobilization
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
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

31. complications of TPN
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

32. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pure motor stroke; limited neurological dysfunction

33. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Abd pain and tenderness; bloody diarrhoea or hematochezia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If any compressive symptoms eg. dysphagia

34. popping sensation; rapid onset of knee effusion. athelet
Urethral stricture; pelvic of urethral trauma
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ACL injury

35. mx of stress fx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Strok and traumatic brain injury

36. most common fx when falling on outsretched hand
4-6 weeks for noncontact sports and longer time for contact sports
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
15-40%; self limiting;doesn't require tx
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

37. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Meniscus injury; medial most common; pain/swelling; popping sensation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check ET tube placement if correct needle decompresion

38. What are the common injuries from lightning?
If any compressive symptoms eg. dysphagia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

39. 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
Seminomas
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

40. ct scan; cystic lesion in head of pancreas; next step
50%; tunneling between rectum or kin
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Headache - ataxia - bulbar dysfunction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

41. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Dumping syndrome; small and frequent meals; no simple sugar
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

42. severe pain in leg after MVC
Less than 5mm
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
SAH due to post communicating artery aneurysm;
Urethral stricture; pelvic of urethral trauma

43. What is prehn sign?
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
L5 to S2

44. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;
Tendons more likely

45. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If any compressive symptoms eg. dysphagia

46. Why varicocele more common in the left side
Mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

47. inhalation of hot air - steam - smoke in burn victim
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Supraglottic edema; low threshold for intubation
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

48. diarrhoea after gastric bypass
Displaced ORIF ; nondisplaced sling immobilization
Dumping syndrome; small and frequent meals; no simple sugar
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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

49. What is hydrocele?
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

50. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
SAH due to post communicating artery aneurysm;
4-6 weeks for noncontact sports and longer time for contact sports