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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 prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

2. 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;
Study showed no adverse effect; but they are contraindicated for PVD
S2-S4
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

3. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Nonunion and avascular necrosis; fx can block blood supply;
Malignancy until proven otherwise

4. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pure motor stroke; limited neurological dysfunction

5. Incidence of AF in CABG patient

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6. tx distal rectal ca
Epi and chest compressio for prolong period of time; atropine is given after epi;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

7. transrectal prostate biopsy
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
Brardycardia - HTN - resp depression
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

8. most common complication of acute cholecystitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Seminomas
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

9. What is hydrocele?
Even after ochiopexy risk of ochiopexy higher then general population
Study showed no adverse effect; but they are contraindicated for PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cystic scrotal fluid collection between parietal and visceral layers of testis

10. anal sphincter tone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
S2-S4
CRPS
Malignancy until proven otherwise

11. stress fx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

12. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Retrograde ejaculation
Amoxicillin-clavulanate
Next best step surgery; not ultrasound

13. How varicocele causes testicular atrophy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

14. What is the complications of undescended testis
Saline and silicone
Even after ochiopexy risk of ochiopexy higher then general population
Urethral stricture; pelvic of urethral trauma
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

15. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
SAH due to post communicating artery aneurysm;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

16. aspiration of breast cyst is nonbloody
10-12 months
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

17. What types of breast implants are available
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Saline and silicone
Mammogram

18. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;
15-40%; self limiting;doesn't require tx

19. what size of ureteral stone for non op mx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Less than 5mm
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

20. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cystic scrotal fluid collection between parietal and visceral layers of testis
Meniscus injury; medial most common; pain/swelling; popping sensation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

21. characteristics of ureteral stone?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Subphrenic abscess or other abdominal abscesses; order US or CT
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

22. popping sensation; rapid onset of knee effusion. athelet
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
24-48 hours of supportive therapy followed by cholecystectomy
ACL injury

23. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

24. Complications of breast impant
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Epi and chest compressio for prolong period of time; atropine is given after epi;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

25. acalculus cholecystitis
Elderly and critically ill patients
Cystic scrotal fluid collection between parietal and visceral layers of testis
Mammogram
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

26. several knee pain after being tackled in football game
24-48 hours of supportive therapy followed by cholecystectomy
Carpal tunnel syndrom
Ispilateral hypoglossal nerve injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

27. What is terrible triad
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
MAT; medial meniscus injury; ACL and Tibial colateral ligament

28. When goiter needs surgery
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dumping syndrome; small and frequent meals; no simple sugar
If any compressive symptoms eg. dysphagia

29. differential of ultrasound finding of breast mass
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Brardycardia - HTN - resp depression
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

30. mx of stress fx
10-12 months
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

31. ct scan; cystic lesion in head of pancreas; next step
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Twisting force with the foot fixed on the ground seen in football and basketball games;

32. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Check ET tube placement if correct needle decompresion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

33. indication of ursodeoxycholic acid
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Check ET tube placement if correct needle decompresion

34. Why ruq calcificaion is concerning
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

35. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
10-12 months
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

36. When to do surgery in undesceneded testis?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cystic scrotal fluid collection between parietal and visceral layers of testis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

37. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

38. lacerated wound in palmer surface of hand. what structure is injured?
Subphrenic abscess or other abdominal abscesses; order US or CT
Tendons more likely
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
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

39. Patient underwent CABG; postoperatively drowsy. most likely cause?
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Retrograde ejaculation

40. How to confirm achiles tendon rupture
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

41. recurrent laryngeal nerve injury
Elderly and critically ill patients
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Unilateral vocal cord paralysis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

42. What is most common lung injury after blunt chest trauma?
Unilateral vocal cord paralysis
Tendons more likely
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
Even after ochiopexy risk of ochiopexy higher then general population

43. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
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
Seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

44. contraindication of urethral catheterization
Ispilateral hypoglossal nerve injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Urethral stricture; pelvic of urethral trauma
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

45. common complication of inadequate mx of scaphoid fx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Nonunion and avascular necrosis; fx can block blood supply;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

46. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
10-12 months

47. scrotal trauma
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Next best step surgery; not ultrasound
Progressive fibrosis of palmar fascia. etiololgy not known;

48. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
L5 to S2
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

49. Tx of proximal non metastatic rectal ca
50%; tunneling between rectum or kin
Progressive fibrosis of palmar fascia. etiololgy not known;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Low anterior resection and radio; add chemo if node positive

50. first line of management of PVD
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare