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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. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

2. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

3. contraindication of urethral catheterization
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
Urethral stricture; pelvic of urethral trauma
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

4. differential of ultrasound finding of breast mass
Strok and traumatic brain injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

5. beta hcg and AFP
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevated non seminomas
Malignancy until proven otherwise

6. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Saline and silicone
Carpal tunnel syndrom

7. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

8. dorsiflexion and planter flexion
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;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Mammogram
L5 to S2

9. swelling and tenderness in anterior part of knee
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension

10. 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
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
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;
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

11. managment of animal bite in hands
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
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;
Malignancy until proven otherwise
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. When goiter needs surgery
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
If any compressive symptoms eg. dysphagia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

13. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mammogram
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

14. When to do surgery in undesceneded testis?
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

15. indication of ursodeoxycholic acid
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

16. Most common of sudden death due to steering wheel injury
Klinefelter syndrome; 50 fold increase;
S2-S4
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

17. aspiration of breast cyst is bloody
Mammogram
Displaced ORIF ; nondisplaced sling immobilization
Pure motor stroke; limited neurological dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

18. 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
Elderly and critically ill patients
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Retrograde ejaculation

19. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Study showed no adverse effect; but they are contraindicated for PVD
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

20. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Low anterior resection and radio; add chemo if node positive
Progressive fibrosis of palmar fascia. etiololgy not known;

21. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
SAH due to post communicating artery aneurysm;

22. 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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
S2-S4
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

23. When do we see complications due to hypophosphatemia
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;
Subphrenic abscess or other abdominal abscesses; order US or CT
Dm neuropathy; stocking glove pattern
Increased size during the day and valsalva means it is communicated with peritoneal cavity

24. Tx of pulmonary contusion
When urethral catherization is unsuccessful
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
SAH due to post communicating artery aneurysm;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Mammogram
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
S2-S4

26. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
L5 to S2
Elderly and critically ill patients

27. What is terrible triad
Klinefelter syndrome; 50 fold increase;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

28. Valgus and Varus tests
Next best step surgery; not ultrasound
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4-6 weeks for noncontact sports and longer time for contact sports

29. stress fx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

30. first step for evaluation of testicular swelling
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. When patient can go back to sports after clavicle fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
10-12 months
4-6 weeks for noncontact sports and longer time for contact sports
Strok and traumatic brain injury

32. how hyperventilation lowers ICP
Cystic scrotal fluid collection between parietal and visceral layers of testis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
When urethral catherization is unsuccessful
Increased size during the day and valsalva means it is communicated with peritoneal cavity

33. beta HCG
Brardycardia - HTN - resp depression
Seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Ispilateral hypoglossal nerve injury

34. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Study showed no adverse effect; but they are contraindicated for PVD

35. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
S2-S4

36. perioral numbness after parathyroidectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

37. recurrent laryngeal nerve injury
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Unilateral vocal cord paralysis

38. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
S2-S4
Displaced ORIF ; nondisplaced sling immobilization
Pure motor stroke; limited neurological dysfunction

39. varicose veins with ulcer - bleeding and thrombophlebitits
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Patellar tendon tear; difficulty in extension
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

40. midline neck swelling moves with protrusion of tongue
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pure motor stroke; limited neurological dysfunction

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Carpal tunnel syndrom
Amoxicillin-clavulanate
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

42. cremasteric reflex test?
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;
Amoxicillin-clavulanate
Urethral stricture; pelvic of urethral trauma
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

43. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

44. How to confirm achiles tendon rupture
Abd pain and tenderness; bloody diarrhoea or hematochezia
Amoxicillin-clavulanate
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
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

45. What is cushing's triad
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Brardycardia - HTN - resp depression
Even after ochiopexy risk of ochiopexy higher then general population

46. How to evaluate painless testicular swelling suspicious for cancer
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
Headache - ataxia - bulbar dysfunction
SAH due to post communicating artery aneurysm;

47. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

48. Dupuytren contracture
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Progressive fibrosis of palmar fascia. etiololgy not known;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

49. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Pure motor stroke; limited neurological dysfunction
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Malignancy until proven otherwise

50. dumping syndrome after gastrectomy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea