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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. Incidence of AF in CABG patient

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2. How varicocele causes testicular atrophy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
ACL injury

3. DD of acute scrotal pain
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Retrograde ejaculation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

4. lacunar stroke
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;
Pure motor stroke; limited neurological dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
24-48 hours of supportive therapy followed by cholecystectomy

5. when scaphoid fx patient needs to be referred to orthopedic
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Less than 5mm
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fx displace >1mm - nonunion during followup - osteonecrosis

6. When goiter needs surgery
If any compressive symptoms eg. dysphagia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

7. Why initial xrays are negative in scaphoid fx
If patient ambulatory - surgery and pain control; if not nonop mx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

8. ct scan; cystic lesion in head of pancreas; next step
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

9. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Unilateral vocal cord paralysis

10. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Tendons more likely
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
50%; tunneling between rectum or kin

11. xray finding of stress fx after 3-4w
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Saline and silicone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

12. What time frame required for bone remodeling
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
10-12 months
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

13. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
50%; tunneling between rectum or kin
ACL injury
Twisting force with the foot fixed on the ground seen in football and basketball games;

14. what size of ureteral stone for non op mx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Less than 5mm
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

15. managment of animal bite in hands
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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;
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

16. What is most common lung injury after blunt chest trauma?
Dumping syndrome; small and frequent meals; no simple sugar
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Compression stocking - weight reduction - leg elevation
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

17. What is cushing's triad
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Brardycardia - HTN - resp depression

18. How to perform lachman test
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Check ET tube placement if correct needle decompresion

19. When to stop raloxifene before surgery
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

20. how hyperventilation lowers ICP
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

21. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Nonunion and avascular necrosis; fx can block blood supply;

22. Indication for bariatric surgery in obese patients
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;
Amoxicillin-clavulanate
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation

23. beta hcg and AFP
Subphrenic abscess or other abdominal abscesses; order US or CT
Ispilateral hypoglossal nerve injury
Elevated non seminomas
Brardycardia - HTN - resp depression

24. aspiration of breast cyst is nonbloody
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Urethral stricture; pelvic of urethral trauma
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

25. dumping syndrome after gastrectomy
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Epi and chest compressio for prolong period of time; atropine is given after epi;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

26. how ABI help dx of PVD
Urethral stricture; pelvic of urethral trauma
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
L5 to S2

27. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Patellar tendon tear; difficulty in extension
S2-S4
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

28. beta HCG
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Nonunion and avascular necrosis; fx can block blood supply;
Seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro

29. Tx of pulmonary contusion
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Displaced ORIF ; nondisplaced sling immobilization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

30. How to differentiate communicative and non-communicative hydrocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

31. recurrent laryngeal nerve injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Unilateral vocal cord paralysis
Ispilateral hypoglossal nerve injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. 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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
ACL injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

33. stress fx
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Unilateral vocal cord paralysis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

34. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
If any compressive symptoms eg. dysphagia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

35. Dupuytren contracture
Klinefelter syndrome; 50 fold increase;
Progressive fibrosis of palmar fascia. etiololgy not known;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

36. characteristics of ureteral stone?
Strok and traumatic brain injury
Brardycardia - HTN - resp depression
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

37. SOB - confusion - petechial rash after trauma - fracture
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

38. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Saline and silicone

39. popping sensation; rapid onset of knee effusion. athelet
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
ACL injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

40. cat/dog bites
Mammogram
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
Amoxicillin-clavulanate
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

41. diarrhoea 4-5 days after cholecystectomy
L5 to S2
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Abd pain and tenderness; bloody diarrhoea or hematochezia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

42. several knee pain after being tackled in football game
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Urethral stricture; pelvic of urethral trauma
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

43. Patient underwent CABG; postoperatively drowsy. most likely cause?
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Increased size during the day and valsalva means it is communicated with peritoneal cavity

44. tx distal rectal ca
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

45. most frequent complication of TURP
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
10-12 months
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Retrograde ejaculation

46. conservative Tx of varicose veins
If any compressive symptoms eg. dysphagia
S2-S4
Compression stocking - weight reduction - leg elevation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

47. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Even after ochiopexy risk of ochiopexy higher then general population
CRPS
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Abd pain and tenderness; bloody diarrhoea or hematochezia

48. Why right varicocele is more concerning?

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49. How to confirm achiles tendon rupture
Check ET tube placement if correct needle decompresion
Elderly and critically ill patients
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro

50. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;