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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. anal sphincter tone
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dm neuropathy; stocking glove pattern
S2-S4

2. What is the strongest risk factor for male breast cancer
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
Dumping syndrome; small and frequent meals; no simple sugar
Klinefelter syndrome; 50 fold increase;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

3. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

4. How to confirm achiles tendon rupture
Patellar tendon tear; difficulty in extension
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
Study showed no adverse effect; but they are contraindicated for PVD
Urethral stricture; pelvic of urethral trauma

5. managment of animal bite in hands
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;
Less than 5mm
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

6. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

7. What is prehn sign?
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
When urethral catherization is unsuccessful

8. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
If any compressive symptoms eg. dysphagia
Tendons more likely
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dm neuropathy; stocking glove pattern

9. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
Unilateral vocal cord paralysis
Progressive fibrosis of palmar fascia. etiololgy not known;

10. mangement of localized lymphadenopathy
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Strok and traumatic brain injury

11. how hyperventilation lowers ICP
CRPS
Nonunion and avascular necrosis; fx can block blood supply;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If any compressive symptoms eg. dysphagia

12. What is the complications of undescended testis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Progressive fibrosis of palmar fascia. etiololgy not known;
Even after ochiopexy risk of ochiopexy higher then general population
Increased size during the day and valsalva means it is communicated with peritoneal cavity

13. varicocele
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Meniscus injury; medial most common; pain/swelling; popping sensation
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

14. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
S2-S4
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

15. beta hcg and AFP
Elderly and critically ill patients
SAH due to post communicating artery aneurysm;
Elevated non seminomas
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

16. prostate enlarged - nontender - no nodularity - elevated PSA
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

17. characteristics of ureteral stone?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

18. perioral numbness after parathyroidectomy
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

19. acute colonic ischemia
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy
Saline and silicone

20. contraindication of urethral catheterization
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
Elevated non seminomas
Urethral stricture; pelvic of urethral trauma

21. What is hungry bone syndrome?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Klinefelter syndrome; 50 fold increase;

22. aspiration of breast cyst is nonbloody
Progressive fibrosis of palmar fascia. etiololgy not known;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
S2-S4

23. How to dx ACL tear?
10-12 months
Mammogram
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

24. management of nondisplaced scaphoid fx
Mammogram
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

25. SOB - confusion - petechial rash after trauma - fracture
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

26. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Study showed no adverse effect; but they are contraindicated for PVD
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

27. transrectal prostate biopsy
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
50%; tunneling between rectum or kin
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

28. Dupuytren contracture
Amoxicillin-clavulanate
Progressive fibrosis of palmar fascia. etiololgy not known;
15-40%; self limiting;doesn't require tx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

29. What is most common lung injury after blunt chest trauma?
Pure motor stroke; limited neurological dysfunction
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

30. What is the contraindication of hyperventilation in inc ICP
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dumping syndrome; small and frequent meals; no simple sugar
Strok and traumatic brain injury
CRPS

31. differential of ultrasound finding of breast mass
Nonunion and avascular necrosis; fx can block blood supply;
If patient ambulatory - surgery and pain control; if not nonop mx
Strok and traumatic brain injury
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

32. How to differentiate ACL and meniscus injury
15-40%; self limiting;doesn't require tx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

33. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
4-6 weeks for noncontact sports and longer time for contact sports

34. first line of management of PVD
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Progressive fibrosis of palmar fascia. etiololgy not known;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

35. Most common of sudden death due to steering wheel injury
Retrograde ejaculation
If patient ambulatory - surgery and pain control; if not nonop mx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury

36. acalculus cholecystitis
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
Elderly and critically ill patients
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

37. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
ACL injury

38. suprapubic catheterization
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
Progressive fibrosis of palmar fascia. etiololgy not known;
When urethral catherization is unsuccessful
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. How to differentiate communicative and non-communicative hydrocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Retrograde ejaculation
Increased size during the day and valsalva means it is communicated with peritoneal cavity

40. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Next best step surgery; not ultrasound
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

41. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Nonunion and avascular necrosis; fx can block blood supply;
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

42. Incidence of AF in CABG patient

43. 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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Twisting force with the foot fixed on the ground seen in football and basketball games;

44. complications of TPN
SAH due to post communicating artery aneurysm;
Pure motor stroke; limited neurological dysfunction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Unilateral vocal cord paralysis

45. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Unilateral vocal cord paralysis
SAH due to post communicating artery aneurysm;
Retrograde ejaculation

46. complication displaced or communited distal radial fx
Malignancy until proven otherwise
Carpal tunnel syndrom
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

47. common complication of inadequate mx of scaphoid fx
Ispilateral hypoglossal nerve injury
Nonunion and avascular necrosis; fx can block blood supply;
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

48. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

49. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
L5 to S2
Elderly and critically ill patients
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

50. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Even after ochiopexy risk of ochiopexy higher then general population
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;