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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.
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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. Indication for bariatric surgery in obese patients
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Nonunion and avascular necrosis; fx can block blood supply;
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
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;

2. 3 mo with groin bulge; bulge appears when child cries
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

3. tx distal rectal ca
Twisting force with the foot fixed on the ground seen in football and basketball games;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Patellar tendon tear; difficulty in extension
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

4. beta HCG
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
Seminomas
Elderly and critically ill patients
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

5. popping sensation; rapid onset of knee effusion. athelet
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation

6. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Supraglottic edema; low threshold for intubation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

7. Why ruq calcificaion is concerning
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Amoxicillin-clavulanate
Elevated non seminomas

8. DD of acute scrotal pain
Patellar tendon tear; difficulty in extension
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

9. when patient with severe lung disease have C02 retention
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
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
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;

10. Why initial xrays are negative in scaphoid fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

11. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

12. most frequent complication of TURP
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Retrograde ejaculation
If any compressive symptoms eg. dysphagia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

13. common complication of inadequate mx of scaphoid fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dumping syndrome; small and frequent meals; no simple sugar
Nonunion and avascular necrosis; fx can block blood supply;

14. How to perform lachman test
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abd pain and tenderness; bloody diarrhoea or hematochezia

15. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
If any compressive symptoms eg. dysphagia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

16. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Compression stocking - weight reduction - leg elevation
SAH due to post communicating artery aneurysm;
If patient ambulatory - surgery and pain control; if not nonop mx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

17. managment of animal bite in hands
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Supraglottic edema; low threshold for intubation

18. clavicle fx
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Displaced ORIF ; nondisplaced sling immobilization
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

19. cremasteric reflex
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Retrograde ejaculation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

20. When to stop raloxifene before surgery
Check ET tube placement if correct needle decompresion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Carpal tunnel syndrom
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

21. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Tendons more likely
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

22. Dupuytren contracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

23. When do we see complications due to hypophosphatemia
Displaced ORIF ; nondisplaced sling immobilization
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;
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

24. What is hydrocele?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dumping syndrome; small and frequent meals; no simple sugar
Cystic scrotal fluid collection between parietal and visceral layers of testis

25. 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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Strok and traumatic brain injury
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

26. types of hip fracture
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

27. When patient can go back to sports after clavicle fx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
4-6 weeks for noncontact sports and longer time for contact sports
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

28. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
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

29. Why right varicocele is more concerning?

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30. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Dm neuropathy; stocking glove pattern
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Check ET tube placement if correct needle decompresion

31. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Progressive fibrosis of palmar fascia. etiololgy not known;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Check ET tube placement if correct needle decompresion

32. How mcmurray manuver perform
Amoxicillin-clavulanate
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

33. when scaphoid fx patient needs to be referred to orthopedic
Ampicillin sublactum - pipercillin - ceftriaxone and metro
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
SAH due to post communicating artery aneurysm;
Fx displace >1mm - nonunion during followup - osteonecrosis

34. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

35. What is most common lung injury after blunt chest trauma?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Low anterior resection and radio; add chemo if node positive
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;

36. beta hcg and AFP
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
Elevated non seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

37. mangement of localized lymphadenopathy
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
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
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;

38. SOB - confusion - petechial rash after trauma - fracture
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

39. severe pain in leg after MVC
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
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
Malignancy until proven otherwise
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Patellar tendon tear; difficulty in extension
L5 to S2
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
SAH due to post communicating artery aneurysm;

41. management of gunshot wound
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

42. painless testicular mass in young male
Supraglottic edema; low threshold for intubation
Malignancy until proven otherwise
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
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

43. first step for evaluation of testicular swelling
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
10-12 months
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

44. complications of TPN
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Check ET tube placement if correct needle decompresion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

45. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Even after ochiopexy risk of ochiopexy higher then general population
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

46. diarrhoea 4-5 days after cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Study showed no adverse effect; but they are contraindicated for PVD
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

47. How to confirm achiles tendon rupture
24-48 hours of supportive therapy followed by cholecystectomy
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

48. What are the common injuries from lightning?
Amoxicillin-clavulanate
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

49. xray finding of stress fx after 3-4w
Low anterior resection and radio; add chemo if node positive
Check ET tube placement if correct needle decompresion
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

50. 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
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
If any compressive symptoms eg. dysphagia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis