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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. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Study showed no adverse effect; but they are contraindicated for PVD
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

2. diarrhoea 4-5 days after cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

3. indication of ursodeoxycholic acid
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

4. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Saline and silicone
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

5. first step for evaluation of testicular swelling
Headache - ataxia - bulbar dysfunction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

6. suprapubic catheterization
When urethral catherization is unsuccessful
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
Displaced ORIF ; nondisplaced sling immobilization
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 types of breast implants are available
Ispilateral hypoglossal nerve injury
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Saline and silicone

8. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Next best step surgery; not ultrasound
Dm neuropathy; stocking glove pattern
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

9. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
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

10. When do we see complications due to hypophosphatemia
Headache - ataxia - bulbar dysfunction
Ispilateral hypoglossal nerve injury
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;
Saline and silicone

11. How to evaluate painless testicular swelling suspicious for cancer
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

12. cremasteric reflex
Cystic scrotal fluid collection between parietal and visceral layers of testis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

13. xray finding of stress fx after 3-4w
L5 to S2
Seminomas
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

14. What time frame required for bone remodeling
10-12 months
Elevated non seminomas
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

15. What is the complications of undescended testis
SAH due to post communicating artery aneurysm;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

16. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Supraglottic edema; low threshold for intubation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

17. Most common of sudden death due to steering wheel injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

18. mangement of localized lymphadenopathy
Pure motor stroke; limited neurological dysfunction
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
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

19. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Brardycardia - HTN - resp depression
Twisting force with the foot fixed on the ground seen in football and basketball games;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

20. How to manage a patient with asystole
S2-S4
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

21. first line of management of PVD
Ispilateral hypoglossal nerve injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Retrograde ejaculation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

22. cremasteric reflex test?
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevated non seminomas
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

23. cat/dog bites
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Amoxicillin-clavulanate

24. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
L5 to S2
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Less than 5mm

25. How to perform lachman test
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

26. What is hydrocele?
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;
S2-S4
Cystic scrotal fluid collection between parietal and visceral layers of testis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

27. swelling and tenderness in anterior part of knee
Even after ochiopexy risk of ochiopexy higher then general population
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 patient ambulatory - surgery and pain control; if not nonop mx
Patellar tendon tear; difficulty in extension

28. clavicle fx
24-48 hours of supportive therapy followed by cholecystectomy
Elderly and critically ill patients
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization

29. mx of stress fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Urethral stricture; pelvic of urethral trauma
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

30. tx distal rectal ca
Less than 5mm
S2-S4
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Even after ochiopexy risk of ochiopexy higher then general population

31. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Elderly and critically ill patients
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mammogram

32. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Even after ochiopexy risk of ochiopexy higher then general population
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
24-48 hours of supportive therapy followed by cholecystectomy

33. varicose veins with ulcer - bleeding and thrombophlebitits
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevated non seminomas
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

34. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

35. beta HCG
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Seminomas

36. surgery for acute cholecystities
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Mammogram
24-48 hours of supportive therapy followed by cholecystectomy

37. severe pain in leg after MVC
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

38. 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
L5 to S2
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

39. most common complication of acute cholecystitis
Progressive fibrosis of palmar fascia. etiololgy not known;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Check ET tube placement if correct needle decompresion
Elevated non seminomas

40. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Next best step surgery; not ultrasound
Dm neuropathy; stocking glove pattern
Elevated non seminomas

41. beta hcg and AFP
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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elevated non seminomas

42. prostate enlarged - nontender - no nodularity - elevated PSA
Supraglottic edema; low threshold for intubation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Displaced ORIF ; nondisplaced sling immobilization
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. Tx of proximal non metastatic rectal ca
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Cystic scrotal fluid collection between parietal and visceral layers of testis
Low anterior resection and radio; add chemo if node positive

44. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Nonunion and avascular necrosis; fx can block blood supply;

45. most common fx when falling on outsretched hand
Cystic scrotal fluid collection between parietal and visceral layers of testis
Subphrenic abscess or other abdominal abscesses; order US or CT
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

46. painless testicular mass in young male
Malignancy until proven otherwise
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

47. management of hip fracture
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If patient ambulatory - surgery and pain control; if not nonop mx
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

48. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If patient ambulatory - surgery and pain control; if not nonop mx

49. anal sphincter tone
Ispilateral hypoglossal nerve injury
S2-S4
Abd pain and tenderness; bloody diarrhoea or hematochezia
Less than 5mm

50. most frequent complication of TURP
Abd pain and tenderness; bloody diarrhoea or hematochezia
10-12 months
Retrograde ejaculation
Less than 5mm