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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 the strongest risk factor for male breast cancer
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
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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;

2. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Seminomas

3. How to perform lachman test
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

4. 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
If patient ambulatory - surgery and pain control; if not nonop mx
Patellar tendon tear; difficulty in extension
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

5. management of nondisplaced scaphoid fx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

6. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
24-48 hours of supportive therapy followed by cholecystectomy

7. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Unilateral vocal cord paralysis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

8. how hyperventilation lowers ICP
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

9. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
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
Study showed no adverse effect; but they are contraindicated for PVD

10. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
If any compressive symptoms eg. dysphagia
Elderly and critically ill patients
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

11. sudden onset of postoperative hyperglycemia when patient on TPN
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Headache - ataxia - bulbar dysfunction
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

12. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

13. acute colonic ischemia
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dumping syndrome; small and frequent meals; no simple sugar
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

14. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram

15. dumping syndrome after gastrectomy
ACL injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Malignancy until proven otherwise
Less than 5mm

16. cat/dog bites
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Amoxicillin-clavulanate
Dm neuropathy; stocking glove pattern

17. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Strok and traumatic brain injury
Dumping syndrome; small and frequent meals; no simple sugar

18. Can we use beta blocker for pvd?
If patient ambulatory - surgery and pain control; if not nonop mx
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS

19. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Mammogram
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. SOB - confusion - petechial rash after trauma - fracture
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Elevated non seminomas

21. popping sensation; rapid onset of knee effusion. athelet
Klinefelter syndrome; 50 fold increase;
Elderly and critically ill patients
ACL injury
S2-S4

22. Most common of sudden death due to steering wheel injury
ACL injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

23. How varicocele causes testicular atrophy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

24. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

25. Indication for bariatric surgery in obese patients
If any compressive symptoms eg. dysphagia
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;
Nonunion and avascular necrosis; fx can block blood supply;
Seminomas

26. what size of ureteral stone for non op mx
Less than 5mm
Mammogram
Unilateral vocal cord paralysis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

27. Why ruq calcificaion is concerning
Carpal tunnel syndrom
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
CRPS

28. When to do surgery in undesceneded testis?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

29. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Saline and silicone

30. ct scan; cystic lesion in head of pancreas; next step
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

31. indication of ursodeoxycholic acid
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

32. complication displaced or communited distal radial fx
Less than 5mm
Carpal tunnel syndrom
10-12 months
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

33. prostate enlarged - nontender - no nodularity - elevated PSA
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Fx displace >1mm - nonunion during followup - osteonecrosis

34. What is the complications of undescended testis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Even after ochiopexy risk of ochiopexy higher then general population
Patellar tendon tear; difficulty in extension

35. mx of stress fx
Unilateral vocal cord paralysis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

36. contraindication of urethral catheterization
When urethral catherization is unsuccessful
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Urethral stricture; pelvic of urethral trauma
Strok and traumatic brain injury

37. dorsiflexion and planter flexion
Compression stocking - weight reduction - leg elevation
L5 to S2
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;
Dumping syndrome; small and frequent meals; no simple sugar

38. diarrhoea 4-5 days after cholecystectomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Even after ochiopexy risk of ochiopexy higher then general population
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

39. lacerated wound in palmer surface of hand. what structure is injured?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Tendons more likely
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

40. clavicle fx
If any compressive symptoms eg. dysphagia
Next best step surgery; not ultrasound
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Displaced ORIF ; nondisplaced sling immobilization

41. management of hip fracture
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
If patient ambulatory - surgery and pain control; if not nonop mx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

42. What percent of anal abscess deveolop fisutula
L5 to S2
Ispilateral hypoglossal nerve injury
50%; tunneling between rectum or kin
Amoxicillin-clavulanate

43. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

44. Complications of breast impant
50%; tunneling between rectum or kin
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Study showed no adverse effect; but they are contraindicated for PVD

45. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Nonunion and avascular necrosis; fx can block blood supply;
Klinefelter syndrome; 50 fold increase;

46. characteristics of ureteral stone?
Carpal tunnel syndrom
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

47. differential of ultrasound finding of breast mass
Compression stocking - weight reduction - leg elevation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

48. aspiration of breast cyst is bloody
Mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dumping syndrome; small and frequent meals; no simple sugar
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

49. how ABI help dx of PVD
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Malignancy until proven otherwise
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

50. When to stop raloxifene before surgery
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Malignancy until proven otherwise