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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. acalculus cholecystitis
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elderly and critically ill patients
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

2. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

3. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

4. How to manage obesity
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
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

5. dorsiflexion and planter flexion
Ispilateral hypoglossal nerve injury
L5 to S2
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury

6. Why right varicocele is more concerning?

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7. sudden onset of postoperative hyperglycemia when patient on TPN
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

8. most common complication of acute cholecystitis
If patient ambulatory - surgery and pain control; if not nonop mx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

9. ipsilateral deviation of tongue upon protrusion
4-6 weeks for noncontact sports and longer time for contact sports
Ispilateral hypoglossal nerve injury
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
Study showed no adverse effect; but they are contraindicated for PVD

10. managment of animal bite in hands
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;
Elderly and critically ill patients
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

11. mangement of localized lymphadenopathy
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

13. perioral numbness after parathyroidectomy
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 injury; medial most common; pain/swelling; popping sensation
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
10-12 months

14. When do we see complications due to hypophosphatemia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;

15. popping sensation; rapid onset of knee effusion. athelet
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
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
ACL injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

16. mx of stress fx
Fx displace >1mm - nonunion during followup - osteonecrosis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

17. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

18. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

19. What is hydrocele?
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Unilateral vocal cord paralysis
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

20. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
L5 to S2
Abd pain and tenderness; bloody diarrhoea or hematochezia
SAH due to post communicating artery aneurysm;

21. Why varicocele more common in the left side
Subphrenic abscess or other abdominal abscesses; order US or CT
Seminomas
10-12 months
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

22. How to differentiate ACL and meniscus injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
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
Twisting force with the foot fixed on the ground seen in football and basketball games;

23. What is prehn sign?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Malignancy until proven otherwise
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

24. diarrhoea 4-5 days after cholecystectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

25. most common fx when falling on outsretched hand
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

26. cat/dog bites
Elderly and critically ill patients
Amoxicillin-clavulanate
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Unilateral vocal cord paralysis

27. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Headache - ataxia - bulbar dysfunction
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Tendons more likely

28. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Amoxicillin-clavulanate
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

29. first step for evaluation of testicular swelling
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

30. scrotal trauma
Next best step surgery; not ultrasound
24-48 hours of supportive therapy followed by cholecystectomy
Elderly and critically ill patients
10-12 months

31. management of hip fracture
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
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

32. DD of acute scrotal pain
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

33. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elderly and critically ill patients

34. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Twisting force with the foot fixed on the ground seen in football and basketball games;
Dm neuropathy; stocking glove pattern
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
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

35. varicocele
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Elevated non seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

36. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
15-40%; self limiting;doesn't require tx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Fx displace >1mm - nonunion during followup - osteonecrosis
Subphrenic abscess or other abdominal abscesses; order US or CT

37. most frequent complication of TURP
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation
Compression stocking - weight reduction - leg elevation

38. what size of ureteral stone for non op mx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

39. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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;
Check ET tube placement if correct needle decompresion
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Supraglottic edema; low threshold for intubation

40. painless testicular mass in young male
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If patient ambulatory - surgery and pain control; if not nonop mx
Malignancy until proven otherwise

41. How to manage a patient with asystole
Ispilateral hypoglossal nerve injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
Compression stocking - weight reduction - leg elevation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

42. varicose veins with ulcer - bleeding and thrombophlebitits
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
Dm neuropathy; stocking glove pattern
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
10-12 months

43. How to differentiate communicative and non-communicative hydrocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

44. severe pain in leg after MVC
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dm neuropathy; stocking glove pattern
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

45. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
CRPS
Less than 5mm

46. How mcmurray manuver perform
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
S2-S4
Next best step surgery; not ultrasound

47. What is most common lung injury after blunt chest trauma?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Dm neuropathy; stocking glove pattern
Twisting force with the foot fixed on the ground seen in football and basketball games;

48. How to confirm achiles tendon rupture
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
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

49. dumping syndrome after gastrectomy
4-6 weeks for noncontact sports and longer time for contact sports
Progressive fibrosis of palmar fascia. etiololgy not known;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

50. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Tendons more likely