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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. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
10-12 months
Patellar tendon tear; difficulty in extension
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

2. cat/dog bites
Pure motor stroke; limited neurological dysfunction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Amoxicillin-clavulanate

3. Dupuytren contracture
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

4. dorsiflexion and planter flexion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
SAH due to post communicating artery aneurysm;
L5 to S2
Dm neuropathy; stocking glove pattern

5. how ABI help dx of PVD
Less than 5mm
Meniscus injury; medial most common; pain/swelling; popping sensation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

6. acalculus cholecystitis
L5 to S2
Elderly and critically ill patients
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

7. varicose veins with ulcer - bleeding and thrombophlebitits
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

8. antibiotics 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
Carpal tunnel syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

9. painless testicular mass in young male
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Malignancy until proven otherwise
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

10. 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
Strok and traumatic brain injury
Displaced ORIF ; nondisplaced sling immobilization
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

11. inhalation of hot air - steam - smoke in burn victim
Low anterior resection and radio; add chemo if node positive
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
Supraglottic edema; low threshold for intubation
L5 to S2

12. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Seminomas
Abd pain and tenderness; bloody diarrhoea or hematochezia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

13. How to manage a patient with asystole
S2-S4
Epi and chest compressio for prolong period of time; atropine is given after epi;
Strok and traumatic brain injury
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;

14. lacunar stroke
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
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction
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

15. first line of management of PVD
Elevated non seminomas
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;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

16. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Strok and traumatic brain injury
Study showed no adverse effect; but they are contraindicated for PVD

17. most frequent complication of TURP
Retrograde ejaculation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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 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

18. cremasteric reflex
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If patient ambulatory - surgery and pain control; if not nonop mx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

19. menisci injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;
L5 to S2

20. diarrhoea after gastric bypass
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dumping syndrome; small and frequent meals; no simple sugar
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

21. transrectal prostate biopsy
Amoxicillin-clavulanate
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

22. How mcmurray manuver perform
Saline and silicone
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Even after ochiopexy risk of ochiopexy higher then general population

23. aspiration of breast cyst is bloody
Mammogram
Next best step surgery; not ultrasound
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
10-12 months

24. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

25. When to do surgery in undesceneded testis?
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
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;
15-40%; self limiting;doesn't require tx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

26. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check ET tube placement if correct needle decompresion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

27. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

28. How to evaluate painless testicular swelling suspicious for cancer
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

29. Tx of pulmonary contusion
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dumping syndrome; small and frequent meals; no simple sugar
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
L5 to S2

30. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

31. complications of TPN
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

32. 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
Unilateral vocal cord paralysis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro

33. Why initial xrays are negative in scaphoid 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
L5 to S2
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

34. perioral numbness after parathyroidectomy
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
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
Carpal tunnel syndrom

35. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

36. Why varicocele more common in the left side
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Seminomas

37. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Urethral stricture; pelvic of urethral trauma
Fx displace >1mm - nonunion during followup - osteonecrosis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Even after ochiopexy risk of ochiopexy higher then general population

38. What is hungry bone syndrome?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
ACL injury

39. ct scan; cystic lesion in head of pancreas; next step
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

40. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis

41. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Strok and traumatic brain injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

42. What are the common injuries from lightning?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
4-6 weeks for noncontact sports and longer time for contact sports
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

43. Can we use beta blocker for pvd?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

44. beta HCG
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
Even after ochiopexy risk of ochiopexy higher then general population
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas

45. DD of acute scrotal pain
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Retrograde ejaculation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

46. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Compression stocking - weight reduction - leg elevation
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

47. swelling and tenderness in anterior part of knee
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation
Patellar tendon tear; difficulty in extension
Pure motor stroke; limited neurological dysfunction

48. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Malignancy until proven otherwise
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

49. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Klinefelter syndrome; 50 fold increase;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

50. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Malignancy until proven otherwise
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;
Subphrenic abscess or other abdominal abscesses; order US or CT