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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. acute colonic ischemia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

2. What is prehn sign?
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

3. what size of ureteral stone for non op mx
Less than 5mm
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cystic scrotal fluid collection between parietal and visceral layers of testis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

4. mangement of localized lymphadenopathy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

5. What is hungry bone syndrome?
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
L5 to S2
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

6. management of hip fracture
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
If patient ambulatory - surgery and pain control; if not nonop mx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

7. How to manage a patient with asystole
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Epi and chest compressio for prolong period of time; atropine is given after epi;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;

8. how hyperventilation lowers ICP
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Elderly and critically ill patients

9. painless testicular mass in young male
Malignancy until proven otherwise
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
When urethral catherization is unsuccessful

10. cat/dog bites
Amoxicillin-clavulanate
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
Displaced ORIF ; nondisplaced sling immobilization
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

11. What time frame required for bone remodeling
10-12 months
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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;
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

12. mx of stress fx
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

13. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Seminomas
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Patellar tendon tear; difficulty in extension

14. anal sphincter tone
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
10-12 months
S2-S4
If any compressive symptoms eg. dysphagia

15. aspiration of breast cyst is bloody
Mammogram
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

16. how ABI help dx of PVD
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Tendons more likely

17. most common fx when falling on outsretched hand
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

18. When to stop raloxifene before surgery
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Nonunion and avascular necrosis; fx can block blood supply;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

19. What is the complications of undescended testis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Even after ochiopexy risk of ochiopexy higher then general population
50%; tunneling between rectum or kin
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

20. Why right varicocele is more concerning?

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21. most common complication of acute cholecystitis
Patellar tendon tear; difficulty in extension
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dumping syndrome; small and frequent meals; no simple sugar

22. lacerated wound in palmer surface of hand. what structure is injured?
24-48 hours of supportive therapy followed by cholecystectomy
Carpal tunnel syndrom
50%; tunneling between rectum or kin
Tendons more likely

23. recurrent laryngeal nerve injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Study showed no adverse effect; but they are contraindicated for PVD
15-40%; self limiting;doesn't require tx
Unilateral vocal cord paralysis

24. cremasteric reflex test?
Mammogram
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
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;

25. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

26. 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
Headache - ataxia - bulbar dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. management of stone 8-10mm
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
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

28. complication displaced or communited distal radial fx
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Carpal tunnel syndrom

29. beta HCG
Pure motor stroke; limited neurological 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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Seminomas

30. lacunar stroke
Meniscus injury; medial most common; pain/swelling; popping sensation
Pure motor stroke; limited neurological dysfunction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

31. What types of breast implants are available
Ispilateral hypoglossal nerve injury
Saline and silicone
L5 to S2
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

32. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pure motor stroke; limited neurological dysfunction
Elderly and critically ill patients

33. How to manage obesity
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;
Malignancy until proven otherwise
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

34. perioral numbness after parathyroidectomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
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
Brardycardia - HTN - resp depression

35. when scaphoid fx patient needs to be referred to orthopedic
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound
Fx displace >1mm - nonunion during followup - osteonecrosis

36. Indication for bariatric surgery in obese patients
Seminomas
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;

37. common complication of inadequate mx of scaphoid fx
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
Nonunion and avascular necrosis; fx can block blood supply;
Ispilateral hypoglossal nerve injury
15-40%; self limiting;doesn't require tx

38. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS
Brardycardia - HTN - resp depression

39. stress fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Compression stocking - weight reduction - leg elevation

40. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

41. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevated non seminomas

42. Valgus and Varus tests
CRPS
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pure motor stroke; limited neurological dysfunction
Brardycardia - HTN - resp depression

43. What is terrible triad
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Displaced ORIF ; nondisplaced sling immobilization
Seminomas
MAT; medial meniscus injury; ACL and Tibial colateral ligament

44. dumping syndrome after gastrectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Compression stocking - weight reduction - leg elevation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cystic scrotal fluid collection between parietal and visceral layers of testis

45. cremasteric reflex
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Patellar tendon tear; difficulty in extension
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

46. indication of ursodeoxycholic acid
If any compressive symptoms eg. dysphagia
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;
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

47. How to confirm achiles tendon rupture
Malignancy until proven otherwise
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
4-6 weeks for noncontact sports and longer time for contact sports

48. How to differentiate ACL and meniscus injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
10-12 months
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

49. When to do surgery in undesceneded testis?
When urethral catherization is unsuccessful
Headache - ataxia - bulbar dysfunction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

50. first line of management of PVD
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Low anterior resection and radio; add chemo if node positive
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;