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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. management of hip fracture
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If patient ambulatory - surgery and pain control; if not nonop mx
Seminomas
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
15-40%; self limiting;doesn't require tx
Progressive fibrosis of palmar fascia. etiololgy not known;

3. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

4. 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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

5. diarrhoea after gastric bypass
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Seminomas
Dumping syndrome; small and frequent meals; no simple sugar

6. when scaphoid fx patient needs to be referred to orthopedic
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Brardycardia - HTN - resp depression
Fx displace >1mm - nonunion during followup - osteonecrosis

7. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

8. what size of ureteral stone for non op mx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Less than 5mm
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dm neuropathy; stocking glove pattern

9. What is terrible triad
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Amoxicillin-clavulanate
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

10. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
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
Strok and traumatic brain injury

11. mangement of localized lymphadenopathy
Supraglottic edema; low threshold for intubation
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dm neuropathy; stocking glove pattern

12. Indication for bariatric surgery in obese patients
Less than 5mm
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;

13. most frequent complication of TURP
Retrograde ejaculation
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Abd pain and tenderness; bloody diarrhoea or hematochezia
Brardycardia - HTN - resp depression

14. most common complication of acute cholecystitis
Carpal tunnel syndrom
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

15. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
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

16. When patient can go back to sports after clavicle fx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
4-6 weeks for noncontact sports and longer time for contact sports
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

17. How to manage obesity
Progressive fibrosis of palmar fascia. etiololgy not known;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If any compressive symptoms eg. dysphagia

18. lacerated wound in palmer surface of hand. what structure is injured?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Tendons more likely
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

19. Can we use beta blocker for pvd?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Study showed no adverse effect; but they are contraindicated for PVD
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

20. Valgus and Varus tests
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Even after ochiopexy risk of ochiopexy higher then general population
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Subphrenic abscess or other abdominal abscesses; order US or CT

21. xray finding of stress fx after 3-4w
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;
S2-S4
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

22. menisci injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Twisting force with the foot fixed on the ground seen in football and basketball games;
ACL injury
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

23. beta hcg and AFP
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;
Elevated non seminomas
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

24. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

25. cremasteric reflex
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Supraglottic edema; low threshold for intubation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

26. suprapubic catheterization
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Mammogram
When urethral catherization is unsuccessful
Progressive fibrosis of palmar fascia. etiololgy not known;

27. How to differentiate ACL and meniscus injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Displaced ORIF ; nondisplaced sling immobilization

28. managment of animal bite in hands
Abd pain and tenderness; bloody diarrhoea or hematochezia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
Mammogram

29. 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
Less than 5mm
When urethral catherization is unsuccessful
ACL injury

30. popping sensation; rapid onset of knee effusion. athelet
Retrograde ejaculation
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
ACL injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

31. How to dx ACL tear?
Saline and silicone
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
SAH due to post communicating artery aneurysm;

32. transrectal prostate biopsy
Saline and silicone
When urethral catherization is unsuccessful
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate

33. What types of breast implants are available
Saline and silicone
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Ispilateral hypoglossal nerve injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

34. Why initial xrays are negative in scaphoid fx
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
If patient ambulatory - surgery and pain control; if not nonop mx
ACL injury
50%; tunneling between rectum or kin

35. How to manage a patient with asystole
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Epi and chest compressio for prolong period of time; atropine is given after epi;
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis

36. Patient underwent CABG; postoperatively drowsy. most likely cause?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Klinefelter syndrome; 50 fold increase;
Elderly and critically ill patients
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

37. scrotal trauma
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Next best step surgery; not ultrasound
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. diarrhoea 4-5 days after cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Ampicillin sublactum - pipercillin - ceftriaxone and metro
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

39. contraindication of urethral catheterization
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Elevated non seminomas
Urethral stricture; pelvic of urethral trauma

40. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Urethral stricture; pelvic of urethral trauma
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Meniscus injury; medial most common; pain/swelling; popping sensation

41. How to confirm achiles tendon rupture
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
4-6 weeks for noncontact sports and longer time for contact sports
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

42. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Brardycardia - HTN - resp depression
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
SAH due to post communicating artery aneurysm;

43. beta HCG
L5 to S2
Seminomas
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

44. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Fx displace >1mm - nonunion during followup - osteonecrosis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Brardycardia - HTN - resp depression

45. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Tendons more likely

46. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Carpal tunnel syndrom
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

47. Tx of pulmonary contusion
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

48. ct scan; cystic lesion in head of pancreas; next step
Carpal tunnel syndrom
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

49. SOB - confusion - petechial rash after trauma - fracture
CRPS
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

50. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
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;
Progressive fibrosis of palmar fascia. etiololgy not known;
15-40%; self limiting;doesn't require tx