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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. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Elderly and critically ill patients
Study showed no adverse effect; but they are contraindicated for PVD
Low anterior resection and radio; add chemo if node positive

2. How varicocele causes testicular atrophy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation
Even after ochiopexy risk of ochiopexy higher then general population
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

3. mx of stress fx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Check ET tube placement if correct needle decompresion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

4. How mcmurray manuver perform
S2-S4
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

5. prostate enlarged - nontender - no nodularity - elevated PSA
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Elevated non seminomas
Less than 5mm

6. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

7. anal sphincter tone
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
S2-S4
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

8. inhalation of hot air - steam - smoke in burn victim
Next best step surgery; not ultrasound
Supraglottic edema; low threshold for intubation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Even after ochiopexy risk of ochiopexy higher then general population

9. differential of ultrasound finding of breast mass
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

10. aspiration of breast cyst is bloody
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Mammogram

11. When do we see complications due to hypophosphatemia
Brardycardia - HTN - resp depression
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. What are the common injuries from lightning?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

13. ipsilateral deviation of tongue upon protrusion
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
Urethral stricture; pelvic of urethral trauma
Ispilateral hypoglossal nerve injury
15-40%; self limiting;doesn't require tx

14. acute colonic ischemia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pure motor stroke; limited neurological dysfunction
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

15. several knee pain after being tackled in football game
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

16. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

17. Why varicocele more common in the left side
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

18. surgery for acute cholecystities
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
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
24-48 hours of supportive therapy followed by cholecystectomy

19. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ampicillin sublactum - pipercillin - ceftriaxone and metro
SAH due to post communicating artery aneurysm;

20. How to differentiate communicative and non-communicative hydrocele
<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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Increased size during the day and valsalva means it is communicated with peritoneal cavity

21. dumping syndrome after gastrectomy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;
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

22. antibiotics of acute cholecystitis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Even after ochiopexy risk of ochiopexy higher then general population
Ampicillin sublactum - pipercillin - ceftriaxone and metro

23. Why ruq calcificaion is concerning
Supraglottic edema; low threshold for intubation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Amoxicillin-clavulanate

24. varicocele
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Carpal tunnel syndrom

25. most common fx when falling on outsretched hand
Displaced ORIF ; nondisplaced sling immobilization
SAH due to post communicating artery aneurysm;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

26. Dupuytren contracture
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;

27. How to confirm achiles tendon rupture
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

28. popping sensation; rapid onset of knee effusion. athelet
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
Amoxicillin-clavulanate
ACL injury
Displaced ORIF ; nondisplaced sling immobilization

29. management of stone 8-10mm
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
15-40%; self limiting;doesn't require tx

31. transrectal prostate biopsy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Displaced ORIF ; nondisplaced sling immobilization
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

32. ct scan; cystic lesion in head of pancreas; next step
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

33. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis
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

34. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Nonunion and avascular necrosis; fx can block blood supply;
Dm neuropathy; stocking glove pattern
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

35. first step for evaluation of testicular swelling
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

36. characteristics of ureteral stone?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Headache - ataxia - bulbar dysfunction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

37. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

38. What is most common lung injury after blunt chest trauma?
Even after ochiopexy risk of ochiopexy higher then general population
Supraglottic edema; low threshold for intubation
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

39. types of hip fracture
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
L5 to S2

40. Can we use beta blocker for pvd?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Study showed no adverse effect; but they are contraindicated for PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

41. Incidence of AF in CABG patient

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42. contraindication of urethral catheterization
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Less than 5mm
Twisting force with the foot fixed on the ground seen in football and basketball games;
Urethral stricture; pelvic of urethral trauma

43. When patient can go back to sports after clavicle fx
Mammogram
4-6 weeks for noncontact sports and longer time for contact sports
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

44. menisci injury
Headache - ataxia - bulbar dysfunction
Twisting force with the foot fixed on the ground seen in football and basketball games;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Displaced ORIF ; nondisplaced sling immobilization

45. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Urethral stricture; pelvic of urethral trauma
Compression stocking - weight reduction - leg elevation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

46. Complications of breast impant
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

47. 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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

48. what size of ureteral stone for non op mx
Less than 5mm
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

49. varicose veins with ulcer - bleeding and thrombophlebitits
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
Compression stocking - weight reduction - leg elevation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

50. how ABI help dx of PVD
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;