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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. how ABI help dx of PVD
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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
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;
Less than 5mm

2. What types of breast implants are available
Saline and silicone
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
Seminomas
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. What is most common lung injury after blunt chest trauma?
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;
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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

4. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
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;
ACL injury
SAH due to post communicating artery aneurysm;

5. perioral numbness after parathyroidectomy
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
SAH due to post communicating artery aneurysm;
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
Elderly and critically ill patients

6. SAH due to posterior inferior cerebellar aneurysm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Headache - ataxia - bulbar dysfunction
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

7. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

8. Indication for bariatric surgery in obese patients
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

9. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

11. How to differentiate ACL and meniscus injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Saline and silicone
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

12. indication of ursodeoxycholic acid
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
50%; tunneling between rectum or kin
Less than 5mm
Seminomas

13. ct scan; cystic lesion in head of pancreas; next step
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Urethral stricture; pelvic of urethral trauma
Cystic scrotal fluid collection between parietal and visceral layers of testis

14. transrectal prostate biopsy
When urethral catherization is unsuccessful
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

15. lacerated wound in palmer surface of hand. what structure is injured?
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Tendons more likely

16. varicose veins with ulcer - bleeding and thrombophlebitits
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
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

17. suprapubic catheterization
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS
When urethral catherization is unsuccessful
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

18. How mcmurray manuver perform
Abd pain and tenderness; bloody diarrhoea or hematochezia
4-6 weeks for noncontact sports and longer time for contact sports
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

19. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dm neuropathy; stocking glove pattern
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
S2-S4

20. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Epi and chest compressio for prolong period of time; atropine is given after epi;
15-40%; self limiting;doesn't require tx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

21. diarrhoea after gastric bypass
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dumping syndrome; small and frequent meals; no simple sugar
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

22. When do we see complications due to hypophosphatemia
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
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;
Brardycardia - HTN - resp depression
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

23. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization

24. cremasteric reflex test?
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
When urethral catherization is unsuccessful

25. stress fx
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
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
S2-S4

26. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Malignancy until proven otherwise
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

27. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
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

28. How to manage a patient with asystole
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Epi and chest compressio for prolong period of time; atropine is given after epi;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

29. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Displaced ORIF ; nondisplaced sling immobilization
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Elevated non seminomas

30. Complications of breast impant
Low anterior resection and radio; add chemo if node positive
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elderly and critically ill patients
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

31. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury
Patellar tendon tear; difficulty in extension
CRPS

32. anal sphincter tone
Dumping syndrome; small and frequent meals; no simple sugar
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
S2-S4

33. When patient can go back to sports after clavicle fx
ACL injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
4-6 weeks for noncontact sports and longer time for contact sports
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;

34. severe pain in leg after MVC
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

35. beta HCG
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
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
Seminomas

36. Tx of proximal non metastatic rectal ca
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Urethral stricture; pelvic of urethral trauma
Check ET tube placement if correct needle decompresion
Low anterior resection and radio; add chemo if node positive

37. SOB - confusion - petechial rash after trauma - fracture
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
SAH due to post communicating artery aneurysm;

38. most common fx when falling on outsretched hand
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;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

39. What is hungry bone syndrome?
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

40. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Elderly and critically ill patients
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

41. scrotal trauma
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
Next best step surgery; not ultrasound
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;
Even after ochiopexy risk of ochiopexy higher then general population

42. Patient underwent CABG; postoperatively drowsy. most likely cause?
Headache - ataxia - bulbar dysfunction
Check ET tube placement if correct needle decompresion
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
50%; tunneling between rectum or kin

43. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Ispilateral hypoglossal nerve injury
Displaced ORIF ; nondisplaced sling immobilization

44. management of hip fracture
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
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
If patient ambulatory - surgery and pain control; if not nonop mx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

45. menisci injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevated non seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;
Headache - ataxia - bulbar dysfunction

46. How to perform lachman test
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

47. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Amoxicillin-clavulanate
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

48. inhalation of hot air - steam - smoke in burn victim
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dumping syndrome; small and frequent meals; no simple sugar
Supraglottic edema; low threshold for intubation

49. types of hip fracture
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Klinefelter syndrome; 50 fold increase;

50. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
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;
50%; tunneling between rectum or kin
Malignancy until proven otherwise