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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 percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Next best step surgery; not ultrasound
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

2. inhalation of hot air - steam - smoke in burn victim
ACL injury
Supraglottic edema; low threshold for intubation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

3. How to confirm achiles tendon rupture
10-12 months
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
Displaced ORIF ; nondisplaced sling immobilization
Dm neuropathy; stocking glove pattern

4. How to dx ACL tear?
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pure motor stroke; limited neurological dysfunction
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

5. Why varicocele more common in the left side
Malignancy until proven otherwise
Supraglottic edema; low threshold for intubation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

6. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Klinefelter syndrome; 50 fold increase;

7. when scaphoid fx patient needs to be referred to orthopedic
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis
Tendons more likely

8. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

9. scrotal trauma
L5 to S2
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
Next best step surgery; not ultrasound
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

10. painless testicular mass in young male
Study showed no adverse effect; but they are contraindicated for PVD
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Malignancy until proven otherwise
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

11. beta hcg and AFP
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
15-40%; self limiting;doesn't require tx
Elevated non seminomas
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

12. ipsilateral deviation of tongue upon protrusion
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Ispilateral hypoglossal nerve injury
Amoxicillin-clavulanate
Urethral stricture; pelvic of urethral trauma

13. How to confirm dx of compartment syndrom
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Supraglottic edema; low threshold for intubation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

14. Patient underwent CABG; postoperatively drowsy. most likely cause?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

15. conservative Tx of varicose veins
Cystic scrotal fluid collection between parietal and visceral layers of testis
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation

16. first step for evaluation of testicular swelling
Klinefelter syndrome; 50 fold increase;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

17. When do we see complications due to hypophosphatemia
Strok and traumatic brain injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

18. SOB - confusion - petechial rash after trauma - fracture
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
Displaced ORIF ; nondisplaced sling immobilization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

19. acute colonic ischemia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abd pain and tenderness; bloody diarrhoea or hematochezia
CRPS
Fx displace >1mm - nonunion during followup - osteonecrosis

20. ct scan; cystic lesion in head of pancreas; next step
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pure motor stroke; limited neurological dysfunction

21. 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
4-6 weeks for noncontact sports and longer time for contact sports
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

22. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Saline and silicone
Subphrenic abscess or other abdominal abscesses; order US or CT
Patellar tendon tear; difficulty in extension
Seminomas

23. management of stone 8-10mm
10-12 months
Fx displace >1mm - nonunion during followup - osteonecrosis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

24. DD of acute scrotal pain
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Next best step surgery; not ultrasound

25. How to evaluate painless testicular swelling suspicious for cancer
L5 to S2
Next best step surgery; not ultrasound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Low anterior resection and radio; add chemo if node positive

26. Why ruq calcificaion is concerning
Less than 5mm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

27. anal sphincter tone
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;
S2-S4
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

28. How to perform lachman test
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

29. how hyperventilation lowers ICP
ACL injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Subphrenic abscess or other abdominal abscesses; order US or CT
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

30. 3 mo with groin bulge; bulge appears when child cries
Seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Ispilateral hypoglossal nerve injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

31. aspiration of breast cyst is nonbloody
Tendons more likely
10-12 months
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
4-6 weeks for noncontact sports and longer time for contact sports

32. mx of stress fx
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

33. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Klinefelter syndrome; 50 fold increase;
Headache - ataxia - bulbar dysfunction

34. What are the common injuries from lightning?
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

35. most frequent complication of TURP
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Fx displace >1mm - nonunion during followup - osteonecrosis
Retrograde ejaculation

36. tx distal rectal ca
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. mangement of localized lymphadenopathy
Abd pain and tenderness; bloody diarrhoea or hematochezia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

38. xray finding of stress fx after 3-4w
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;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia

39. Indication for bariatric surgery in obese patients
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;

40. management of gunshot wound
Check ET tube placement if correct needle decompresion
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;
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
If patient ambulatory - surgery and pain control; if not nonop mx

41. complications of TPN
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension
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

42. What is cushing's triad
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Compression stocking - weight reduction - leg elevation
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression

43. Incidence of AF in CABG patient

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44. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Mammogram
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

45. 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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Amoxicillin-clavulanate
Tendons more likely

46. When to stop raloxifene before surgery
24-48 hours of supportive therapy followed by cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
4-6 weeks for noncontact sports and longer time for contact sports
Low anterior resection and radio; add chemo if node positive

47. What is terrible triad
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
4-6 weeks for noncontact sports and longer time for contact sports
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

48. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
10-12 months
ACL injury
CRPS

49. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Malignancy until proven otherwise
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

50. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament