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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 to manage obesity
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
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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

2. SAH due to posterior inferior cerebellar aneurysm
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Headache - ataxia - bulbar dysfunction
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
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;

3. management of gunshot wound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Dumping syndrome; small and frequent meals; no simple sugar
Displaced ORIF ; nondisplaced sling immobilization

4. Why ruq calcificaion is concerning
Even after ochiopexy risk of ochiopexy higher then general population
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Next best step surgery; not ultrasound
If patient ambulatory - surgery and pain control; if not nonop mx

5. How varicocele causes testicular atrophy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
When urethral catherization is unsuccessful
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

6. suprapubic catheterization
Compression stocking - weight reduction - leg elevation
Fx displace >1mm - nonunion during followup - osteonecrosis
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful

7. Complications of breast impant
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
L5 to S2
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

8. ct scan; cystic lesion in head of pancreas; next step
Saline and silicone
Nonunion and avascular necrosis; fx can block blood supply;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

9. diarrhoea after gastric bypass
Study showed no adverse effect; but they are contraindicated for PVD
Klinefelter syndrome; 50 fold increase;
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
Dumping syndrome; small and frequent meals; no simple sugar

10. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Low anterior resection and radio; add chemo if node positive
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

11. complication displaced or communited distal radial fx
Carpal tunnel syndrom
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
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

12. midline neck swelling moves with protrusion of tongue
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Malignancy until proven otherwise

13. cremasteric reflex test?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

14. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Epi and chest compressio for prolong period of time; atropine is given after epi;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

15. How to confirm achiles tendon rupture
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
L5 to S2
Ampicillin sublactum - pipercillin - ceftriaxone and metro

16. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elderly and critically ill patients
Dm neuropathy; stocking glove pattern

17. dorsiflexion and planter flexion
If patient ambulatory - surgery and pain control; if not nonop mx
L5 to S2
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Tendons more likely

18. Why right varicocele is more concerning?

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19. surgery for acute cholecystities
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
24-48 hours of supportive therapy followed by cholecystectomy

20. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Amoxicillin-clavulanate

21. Tx of proximal non metastatic rectal ca
24-48 hours of supportive therapy followed by cholecystectomy
Low anterior resection and radio; add chemo if node positive
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

22. several knee pain after being tackled in football game
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Elderly and critically ill patients
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

23. How to confirm dx of compartment syndrom
SAH due to post communicating artery aneurysm;
L5 to S2
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

24. most common complication of acute cholecystitis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

25. acalculus cholecystitis
50%; tunneling between rectum or kin
Elderly and critically ill patients
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Even after ochiopexy risk of ochiopexy higher then general population

26. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Tendons more likely

27. beta HCG
Seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months

28. types of hip fracture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension

29. Why varicocele more common in the left side
4-6 weeks for noncontact sports and longer time for contact sports
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

30. management of hip fracture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
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

31. When to stop raloxifene before surgery
Abd pain and tenderness; bloody diarrhoea or hematochezia
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

32. What is hungry bone syndrome?
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Displaced ORIF ; nondisplaced sling immobilization

33. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Check ET tube placement if correct needle decompresion
Strok and traumatic brain injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament

34. How mcmurray manuver perform
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Displaced ORIF ; nondisplaced sling immobilization

35. pregnant patient with asymptomatic gall stones
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pure motor stroke; limited neurological dysfunction
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

36. Patient underwent CABG; postoperatively drowsy. most likely cause?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
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

37. what size of ureteral stone for non op mx
Brardycardia - HTN - resp depression
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
SAH due to post communicating artery aneurysm;
Less than 5mm

38. What time frame required for bone remodeling
10-12 months
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

39. What is the complications of undescended testis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Even after ochiopexy risk of ochiopexy higher then general population
Meniscus injury; medial most common; pain/swelling; popping sensation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

40. antibiotics of acute cholecystitis
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
MAT; medial meniscus injury; ACL and Tibial colateral ligament

41. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro

42. management of stone 8-10mm
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;
Study showed no adverse effect; but they are contraindicated for PVD
Ispilateral hypoglossal nerve injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

43. When patient can go back to sports after clavicle fx
L5 to S2
24-48 hours of supportive therapy followed by cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports
Meniscus injury; medial most common; pain/swelling; popping sensation

44. cremasteric reflex
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ACL injury
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ampicillin sublactum - pipercillin - ceftriaxone and metro

45. 3 mo with groin bulge; bulge appears when child cries
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Meniscus injury; medial most common; pain/swelling; popping sensation
Compression stocking - weight reduction - leg elevation

46. Tx of pulmonary contusion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

47. lacunar stroke
Malignancy until proven otherwise
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Pure motor stroke; limited neurological dysfunction

48. 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;
Check ET tube placement if correct needle decompresion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Klinefelter syndrome; 50 fold increase;

49. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Retrograde ejaculation
L5 to S2

50. dumping syndrome after gastrectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Twisting force with the foot fixed on the ground seen in football and basketball games;
ACL injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea