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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. What is cushing's triad
Brardycardia - HTN - resp depression
Saline and silicone
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

2. Indication for bariatric surgery in obese patients
50%; tunneling between rectum or kin
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
When urethral catherization is unsuccessful
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

4. What is the strongest risk factor for male breast cancer
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Fx displace >1mm - nonunion during followup - osteonecrosis
Klinefelter syndrome; 50 fold increase;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

5. Dupuytren contracture
S2-S4
Progressive fibrosis of palmar fascia. etiololgy not known;
15-40%; self limiting;doesn't require tx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

6. tx distal rectal ca
Check ET tube placement if correct needle decompresion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Displaced ORIF ; nondisplaced sling immobilization
Sphincter sparing surgery (local resection) - abdomnio perineal resection

7. menisci injury
Nonunion and avascular necrosis; fx can block blood supply;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Twisting force with the foot fixed on the ground seen in football and basketball games;

8. acalculus cholecystitis
Fx displace >1mm - nonunion during followup - osteonecrosis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

9. most common complication of acute cholecystitis
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

10. Patient underwent CABG; postoperatively drowsy. most likely cause?
Mammogram
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Dumping syndrome; small and frequent meals; no simple sugar

11. when patient with severe lung disease have C02 retention
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
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

12. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Malignancy until proven otherwise
Subphrenic abscess or other abdominal abscesses; order US or CT
Sphincter sparing surgery (local resection) - abdomnio perineal resection
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

13. differential of ultrasound finding of breast mass
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament

14. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

15. types of hip fracture
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
L5 to S2

16. When goiter needs surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If any compressive symptoms eg. dysphagia
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Patellar tendon tear; difficulty in extension

17. clavicle fx
L5 to S2
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Displaced ORIF ; nondisplaced sling immobilization
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

18. management of hip fracture
Malignancy until proven otherwise
If patient ambulatory - surgery and pain control; if not nonop mx
4-6 weeks for noncontact sports and longer time for contact sports
Retrograde ejaculation

19. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

20. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
SAH due to post communicating artery aneurysm;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Saline and silicone

21. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Meniscus injury; medial most common; pain/swelling; popping sensation
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

22. xray finding of stress fx after 3-4w
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dumping syndrome; small and frequent meals; no simple sugar
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

23. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
When urethral catherization is unsuccessful
Dm neuropathy; stocking glove pattern
Twisting force with the foot fixed on the ground seen in football and basketball games;

24. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Saline and silicone
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

25. management of gunshot wound
Malignancy until proven otherwise
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
When urethral catherization is unsuccessful
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

26. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Compression stocking - weight reduction - leg elevation
Check ET tube placement if correct needle decompresion
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. swelling and tenderness in anterior part of knee
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Elevated non seminomas
Patellar tendon tear; difficulty in extension

28. diarrhoea after gastric bypass
If any compressive symptoms eg. dysphagia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Dumping syndrome; small and frequent meals; no simple sugar

29. antibiotics of acute cholecystitis
Dm neuropathy; stocking glove pattern
10-12 months
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Epi and chest compressio for prolong period of time; atropine is given after epi;

30. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

31. 3 mo with groin bulge; bulge appears when child cries
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

32. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Less than 5mm
Klinefelter syndrome; 50 fold increase;
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

33. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
Pure motor stroke; limited neurological dysfunction

34. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Retrograde ejaculation
Dm neuropathy; stocking glove pattern

35. sudden onset of postoperative hyperglycemia when patient on TPN
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

36. How to differentiate ACL and meniscus injury
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
4-6 weeks for noncontact sports and longer time for contact sports
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

37. pregnant patient with asymptomatic gall stones
Elderly and critically ill patients
Low anterior resection and radio; add chemo if node positive
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
50%; tunneling between rectum or kin

38. How to confirm achiles tendon rupture
Headache - ataxia - bulbar dysfunction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Strok and traumatic brain injury

39. Valgus and Varus tests
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Saline and silicone
MAT; medial meniscus injury; ACL and Tibial colateral ligament

40. managment of animal bite in hands
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
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
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;
Subphrenic abscess or other abdominal abscesses; order US or CT

41. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

42. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. SOB - confusion - petechial rash after trauma - fracture
Saline and silicone
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

44. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Dm neuropathy; stocking glove pattern
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports

45. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
24-48 hours of supportive therapy followed by cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

46. when scaphoid fx patient needs to be referred to orthopedic
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
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

47. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;
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
Even after ochiopexy risk of ochiopexy higher then general population

48. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Displaced ORIF ; nondisplaced sling immobilization

49. How to differentiate communicative and non-communicative hydrocele
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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 size during the day and valsalva means it is communicated with peritoneal cavity

50. most frequent complication of TURP
ACL injury
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
Retrograde ejaculation