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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. first step for evaluation of testicular swelling
4-6 weeks for noncontact sports and longer time for contact sports
Brardycardia - HTN - resp depression
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

2. diarrhoea after gastric bypass
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check ET tube placement if correct needle decompresion
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
Dumping syndrome; small and frequent meals; no simple sugar

3. Indication for bariatric surgery in obese patients
Even after ochiopexy risk of ochiopexy higher then general population
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Retrograde ejaculation
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;

4. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Tendons more likely
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

5. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Tendons more likely
Twisting force with the foot fixed on the ground seen in football and basketball games;
SAH due to post communicating artery aneurysm;

6. dorsiflexion and planter flexion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
L5 to S2
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

7. 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
Dm neuropathy; stocking glove pattern
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Compression stocking - weight reduction - leg elevation

8. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Compression stocking - weight reduction - leg elevation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

9. What is the contraindication of hyperventilation in inc ICP
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Carpal tunnel syndrom
Strok and traumatic brain injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

10. sudden onset of postoperative hyperglycemia when patient on TPN
Fx displace >1mm - nonunion during followup - osteonecrosis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
10-12 months

11. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Progressive fibrosis of palmar fascia. etiololgy not known;

12. when scaphoid fx patient needs to be referred to orthopedic
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

13. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

14. beta hcg and AFP
Elevated non seminomas
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

15. Tx of proximal non metastatic rectal ca
Unilateral vocal cord paralysis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Low anterior resection and radio; add chemo if node positive
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

16. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

17. cremasteric reflex
Fx displace >1mm - nonunion during followup - osteonecrosis
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

18. differential of ultrasound finding of breast mass
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Elevated non seminomas
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

19. inhalation of hot air - steam - smoke in burn victim
ACL injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Supraglottic edema; low threshold for intubation
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

20. most common fx when falling on outsretched hand
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

21. acalculus cholecystitis
When urethral catherization is unsuccessful
Dm neuropathy; stocking glove pattern
Elderly and critically ill patients
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

22. beta HCG
Seminomas
10-12 months
Meniscus injury; medial most common; pain/swelling; popping sensation
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

23. how hyperventilation lowers ICP
Elevated non seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

24. What is hungry bone syndrome?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Klinefelter syndrome; 50 fold increase;
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation
Meniscus injury; medial most common; pain/swelling; popping sensation

26. management of stone 8-10mm
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
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

27. complications of TPN
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

28. lacerated wound in palmer surface of hand. what structure is injured?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Tendons more likely

29. first line of management of PVD
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

30. midline neck swelling moves with protrusion of tongue
Displaced ORIF ; nondisplaced sling immobilization
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

31. surgery for acute cholecystities
Even after ochiopexy risk of ochiopexy higher then general population
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
24-48 hours of supportive therapy followed by cholecystectomy

32. characteristics of ureteral stone?
Meniscus injury; medial most common; pain/swelling; popping sensation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

33. Patient underwent CABG; postoperatively drowsy. most likely cause?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
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
Carpal tunnel syndrom

34. suprapubic catheterization
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Nonunion and avascular necrosis; fx can block blood supply;
When urethral catherization is unsuccessful

35. When do we see complications due to hypophosphatemia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

36. When to stop raloxifene before surgery
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevated non seminomas

37. when patient with severe lung disease have C02 retention
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elderly and critically ill patients

38. What is most common lung injury after blunt chest trauma?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
Carpal tunnel syndrom
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

39. several knee pain after being tackled in football game
ACL injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports

40. What is cushing's triad
L5 to S2
Study showed no adverse effect; but they are contraindicated for PVD
Brardycardia - HTN - resp depression
Epi and chest compressio for prolong period of time; atropine is given after epi;

41. mangement of localized lymphadenopathy
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dumping syndrome; small and frequent meals; no simple sugar
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

42. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Patellar tendon tear; difficulty in extension
15-40%; self limiting;doesn't require tx
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. management of nondisplaced scaphoid fx
Unilateral vocal cord paralysis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

44. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Strok and traumatic brain injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

45. Most common of sudden death due to steering wheel injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

46. managment of animal bite in hands
L5 to S2
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
When urethral catherization is unsuccessful

47. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Saline and silicone

48. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

49. severe pain in leg after MVC
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
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
Patellar tendon tear; difficulty in extension

50. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Study showed no adverse effect; but they are contraindicated for PVD