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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. management of nondisplaced scaphoid fx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Subphrenic abscess or other abdominal abscesses; order US or CT
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

2. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Saline and silicone
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

3. varicose veins with ulcer - bleeding and thrombophlebitits
Next best step surgery; not ultrasound
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Malignancy until proven otherwise

4. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Malignancy until proven otherwise
Supraglottic edema; low threshold for intubation
Meniscus injury; medial most common; pain/swelling; popping sensation

5. How to confirm achiles tendon rupture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Fx displace >1mm - nonunion during followup - osteonecrosis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

6. What percent of anal abscess deveolop fisutula
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
50%; tunneling between rectum or kin
Ispilateral hypoglossal nerve injury
Klinefelter syndrome; 50 fold increase;

7. beta hcg and AFP
Elevated non seminomas
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Urethral stricture; pelvic of urethral trauma

8. How to differentiate communicative and non-communicative hydrocele
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Saline and silicone
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

9. Why ruq calcificaion is concerning
Fx displace >1mm - nonunion during followup - osteonecrosis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

10. how hyperventilation lowers ICP
4-6 weeks for noncontact sports and longer time for contact sports
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

11. mx of stress fx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

12. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Check ET tube placement if correct needle decompresion
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

13. surgery for acute cholecystities
Elderly and critically ill patients
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
24-48 hours of supportive therapy followed by cholecystectomy

14. Valgus and Varus tests
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

15. How to confirm dx of compartment syndrom
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ACL injury
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

16. prostate enlarged - nontender - no nodularity - elevated PSA
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;
10-12 months
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

17. when patient with severe lung disease have C02 retention
Ampicillin sublactum - pipercillin - ceftriaxone and metro
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Check ET tube placement if correct needle decompresion
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

18. popping sensation; rapid onset of knee effusion. athelet
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
ACL injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
S2-S4

19. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
CRPS
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

20. Patient underwent CABG; postoperatively drowsy. most likely cause?
Epi and chest compressio for prolong period of time; atropine is given after epi;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Urethral stricture; pelvic of urethral trauma

21. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Patellar tendon tear; difficulty in extension
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;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

22. cremasteric reflex
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

23. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Strok and traumatic brain injury
Nonunion and avascular necrosis; fx can block blood supply;
SAH due to post communicating artery aneurysm;

24. What are the common injuries from lightning?
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Nonunion and avascular necrosis; fx can block blood supply;

25. contraindication of urethral catheterization
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Brardycardia - HTN - resp depression
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Urethral stricture; pelvic of urethral trauma

26. 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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Malignancy until proven otherwise
When urethral catherization is unsuccessful

27. transrectal prostate biopsy
Compression stocking - weight reduction - leg elevation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

28. When patient can go back to sports after clavicle fx
Amoxicillin-clavulanate
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
4-6 weeks for noncontact sports and longer time for contact sports

29. clavicle fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
L5 to S2
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Displaced ORIF ; nondisplaced sling immobilization

30. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

31. inhalation of hot air - steam - smoke in burn victim
CRPS
Subphrenic abscess or other abdominal abscesses; order US or CT
Supraglottic edema; low threshold for intubation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

32. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
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

33. Tx of pulmonary contusion
Brardycardia - HTN - resp depression
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

34. How to evaluate painless testicular swelling suspicious for cancer
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

35. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
50%; tunneling between rectum or kin
Displaced ORIF ; nondisplaced sling immobilization

36. anal sphincter tone
S2-S4
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

37. Why right varicocele is more concerning?

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38. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
S2-S4
Ampicillin sublactum - pipercillin - ceftriaxone and metro
50%; tunneling between rectum or kin

39. menisci 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
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

40. most common complication of acute cholecystitis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Unilateral vocal cord paralysis
Twisting force with the foot fixed on the ground seen in football and basketball games;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

41. complications of TPN
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

42. severe pain in leg after MVC
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
15-40%; self limiting;doesn't require tx
Pure motor stroke; limited neurological dysfunction

43. 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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased size during the day and valsalva means it is communicated with peritoneal cavity

44. first line of management of PVD
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
15-40%; self limiting;doesn't require tx

45. most frequent complication of TURP
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Unilateral vocal cord paralysis
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
Retrograde ejaculation

46. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Abd pain and tenderness; bloody diarrhoea or hematochezia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

47. how ABI help dx of PVD
Pure motor stroke; limited neurological dysfunction
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
Displaced ORIF ; nondisplaced sling immobilization
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

48. indication of ursodeoxycholic acid
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

49. cat/dog bites
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Amoxicillin-clavulanate
Saline and silicone
4-6 weeks for noncontact sports and longer time for contact sports

50. ct scan; cystic lesion in head of pancreas; next step
ACL injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Even after ochiopexy risk of ochiopexy higher then general population
Sphincter sparing surgery (local resection) - abdomnio perineal resection