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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. suprapubic catheterization
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Amoxicillin-clavulanate
4-6 weeks for noncontact sports and longer time for contact sports
When urethral catherization is unsuccessful

2. common complication of inadequate mx of scaphoid fx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Nonunion and avascular necrosis; fx can block blood supply;
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

3. several knee pain after being tackled in football game
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Sphincter sparing surgery (local resection) - abdomnio perineal resection

4. When to stop raloxifene before surgery
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
Patellar tendon tear; difficulty in extension
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. How mcmurray manuver perform
Less than 5mm
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

6. varicose veins with ulcer - bleeding and thrombophlebitits
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

7. mangement of localized lymphadenopathy
Klinefelter syndrome; 50 fold increase;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Progressive fibrosis of palmar fascia. etiololgy not known;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

8. What is hydrocele?
Strok and traumatic brain injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
10-12 months
Less than 5mm

9. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Headache - ataxia - bulbar dysfunction
Malignancy until proven otherwise
Sphincter sparing surgery (local resection) - abdomnio perineal resection

10. What is cushing's triad
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Brardycardia - HTN - resp depression
24-48 hours of supportive therapy followed by cholecystectomy

11. xray finding of stress fx after 3-4w
Low anterior resection and radio; add chemo if node positive
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Ispilateral hypoglossal nerve injury
Supraglottic edema; low threshold for intubation

12. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Check ET tube placement if correct needle decompresion

13. beta hcg and AFP
Fx displace >1mm - nonunion during followup - osteonecrosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elevated non seminomas
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

14. Tx of proximal non metastatic rectal ca
Tendons more likely
Displaced ORIF ; nondisplaced sling immobilization
Low anterior resection and radio; add chemo if node positive
15-40%; self limiting;doesn't require tx

15. varicocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Less than 5mm
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

16. when patient with severe lung disease have C02 retention
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Next best step surgery; not ultrasound
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

17. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Elderly and critically ill patients
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

18. conservative Tx of varicose veins
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury

19. beta HCG
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
Seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Elderly and critically ill patients

20. Can we use beta blocker for pvd?
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Study showed no adverse effect; but they are contraindicated for PVD
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

21. menisci injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

22. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Seminomas
Unilateral vocal cord paralysis
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

23. acalculus cholecystitis
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;
Brardycardia - HTN - resp depression
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Elderly and critically ill patients

24. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Strok and traumatic brain injury
If patient ambulatory - surgery and pain control; if not nonop mx

25. 3 mo with groin bulge; bulge appears when child cries
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Subphrenic abscess or other abdominal abscesses; order US or CT

26. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

27. How to dx ACL tear?
Strok and traumatic brain injury
Headache - ataxia - bulbar dysfunction
L5 to S2
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

28. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
50%; tunneling between rectum or kin
Amoxicillin-clavulanate

29. What are the common injuries from lightning?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cystic scrotal fluid collection between parietal and visceral layers of testis

30. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Low anterior resection and radio; add chemo if node positive
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

31. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;

32. differential of ultrasound finding of breast mass
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

33. how ABI help dx of PVD
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

34. acute colonic ischemia
Progressive fibrosis of palmar fascia. etiololgy not known;
Unilateral vocal cord paralysis
When urethral catherization is unsuccessful
Abd pain and tenderness; bloody diarrhoea or hematochezia

35. Why initial xrays are negative in scaphoid fx
50%; tunneling between rectum or kin
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Carpal tunnel syndrom
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

36. management of nondisplaced scaphoid fx
Seminomas
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. contraindication of urethral catheterization
Malignancy until proven otherwise
Urethral stricture; pelvic of urethral trauma
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

38. Dupuytren contracture
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Progressive fibrosis of palmar fascia. etiololgy not known;
Study showed no adverse effect; but they are contraindicated for PVD
Meniscus injury; medial most common; pain/swelling; popping sensation

39. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

40. What is the strongest risk factor for male breast cancer
Next best step surgery; not ultrasound
Klinefelter syndrome; 50 fold increase;
Saline and silicone
Even after ochiopexy risk of ochiopexy higher then general population

41. How varicocele causes testicular atrophy
Dumping syndrome; small and frequent meals; no simple sugar
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

42. pregnant patient with asymptomatic gall stones
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Low anterior resection and radio; add chemo if node positive
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

43. DD of acute scrotal pain
Klinefelter syndrome; 50 fold increase;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

44. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Urethral stricture; pelvic of urethral trauma

45. surgery for acute cholecystities
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy
Tendons more likely
Headache - ataxia - bulbar dysfunction

46. complications of TPN
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx

47. painless testicular mass in young male
Malignancy until proven otherwise
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;

48. What is hungry bone syndrome?
Patellar tendon tear; difficulty in extension
Epi and chest compressio for prolong period of time; atropine is given after epi;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

49. What is the complications of undescended testis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Even after ochiopexy risk of ochiopexy higher then general population
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele