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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. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cystic scrotal fluid collection between parietal and visceral layers of testis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Mammogram

2. stress fx
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
Tendons more likely
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Subphrenic abscess or other abdominal abscesses; order US or CT

3. Valgus and Varus tests
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

4. What time frame required for bone remodeling
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
10-12 months
Headache - ataxia - bulbar dysfunction
If any compressive symptoms eg. dysphagia

5. xray finding of stress fx after 3-4w
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Strok and traumatic brain injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
50%; tunneling between rectum or kin

6. anal sphincter tone
S2-S4
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

7. cremasteric reflex
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Compression stocking - weight reduction - leg elevation

8. types of hip fracture
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
CRPS

9. first line of management of PVD
Mammogram
SAH due to post communicating artery aneurysm;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

10. aspiration of breast cyst is nonbloody
Subphrenic abscess or other abdominal abscesses; order US or CT
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
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

11. What is hydrocele?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

12. first step for evaluation of testicular swelling
Elevated non seminomas
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

13. cat/dog bites
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Amoxicillin-clavulanate
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
Even after ochiopexy risk of ochiopexy higher then general population

14. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
L5 to S2
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

15. mx of stress fx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

16. aspiration of breast cyst is bloody
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

17. What types of breast implants are available
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Saline and silicone
Fx displace >1mm - nonunion during followup - osteonecrosis

18. Why ruq calcificaion is concerning
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Less than 5mm
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

19. dumping syndrome after gastrectomy
Next best step surgery; not ultrasound
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
Urethral stricture; pelvic of urethral trauma
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

20. midline neck swelling moves with protrusion of tongue
Check ET tube placement if correct needle decompresion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

21. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
15-40%; self limiting;doesn't require tx
Pure motor stroke; limited neurological dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Even after ochiopexy risk of ochiopexy higher then general population

22. antibiotics of acute cholecystitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation

23. acalculus cholecystitis
Pure motor stroke; limited neurological dysfunction
Elderly and critically ill patients
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
Mammogram

24. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Study showed no adverse effect; but they are contraindicated for PVD
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

25. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
S2-S4

26. DD of acute scrotal pain
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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dumping syndrome; small and frequent meals; no simple sugar
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

27. ct scan; cystic lesion in head of pancreas; next step
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Displaced ORIF ; nondisplaced sling immobilization
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

28. indication of ursodeoxycholic acid
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
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
Brardycardia - HTN - resp depression

29. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months
15-40%; self limiting;doesn't require tx
Check ET tube placement if correct needle decompresion

30. When do we see complications due to hypophosphatemia
Malignancy until proven otherwise
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;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Mammogram

31. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Less than 5mm
Dm neuropathy; stocking glove pattern
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

32. How to manage obesity
Twisting force with the foot fixed on the ground seen in football and basketball games;
Unilateral vocal cord paralysis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

33. How to manage a patient with asystole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

34. What is the contraindication of hyperventilation in inc ICP
Displaced ORIF ; nondisplaced sling immobilization
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury

35. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
SAH due to post communicating artery aneurysm;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS
Klinefelter syndrome; 50 fold increase;

36. Why initial xrays are negative in scaphoid fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
Dm neuropathy; stocking glove pattern
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

37. clavicle fx
Unilateral vocal cord paralysis
Displaced ORIF ; nondisplaced sling immobilization
Seminomas
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

38. several knee pain after being tackled in football game
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Mammogram
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

39. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

40. How to confirm dx of compartment syndrom
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Urethral stricture; pelvic of urethral trauma
Elevated non seminomas

41. acute colonic ischemia
Supraglottic edema; low threshold for intubation
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Abd pain and tenderness; bloody diarrhoea or hematochezia

42. What percent of anal abscess deveolop fisutula
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
50%; tunneling between rectum or kin
Patellar tendon tear; difficulty in extension
Epi and chest compressio for prolong period of time; atropine is given after epi;

43. What is hungry bone syndrome?
Brardycardia - HTN - resp depression
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
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
Study showed no adverse effect; but they are contraindicated for PVD

44. recurrent laryngeal nerve injury
Retrograde ejaculation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

45. When goiter needs surgery
Dm neuropathy; stocking glove pattern
Progressive fibrosis of palmar fascia. etiololgy not known;
If any compressive symptoms eg. dysphagia
Elevated non seminomas

46. dorsiflexion and planter flexion
L5 to S2
Malignancy until proven otherwise
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

47. How to differentiate ACL and meniscus injury
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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;
Klinefelter syndrome; 50 fold increase;

48. varicose veins with ulcer - bleeding and thrombophlebitits
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;
Mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

49. Tx of proximal non metastatic rectal ca
Cystic scrotal fluid collection between parietal and visceral layers of testis
Seminomas
Low anterior resection and radio; add chemo if node positive
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

50. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
4-6 weeks for noncontact sports and longer time for contact sports
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;