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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. DD of acute scrotal pain
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Progressive fibrosis of palmar fascia. etiololgy not known;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

2. Why initial xrays are negative in scaphoid fx
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

3. diarrhoea after gastric bypass
Saline and silicone
Dumping syndrome; small and frequent meals; no simple sugar
Dm neuropathy; stocking glove pattern
Retrograde ejaculation

4. how ABI help dx of PVD
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Tendons more likely
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

5. Dupuytren contracture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Progressive fibrosis of palmar fascia. etiololgy not known;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

6. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pure motor stroke; limited neurological dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;

7. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Strok and traumatic brain injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

8. Can we use beta blocker for pvd?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Study showed no adverse effect; but they are contraindicated for PVD

9. How to evaluate painless testicular swelling suspicious for cancer
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Carpal tunnel syndrom
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

10. varicocele
Check ET tube placement if correct needle decompresion
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Subphrenic abscess or other abdominal abscesses; order US or CT

11. How to confirm achiles tendon rupture
Mammogram
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
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

12. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Less than 5mm

13. management of gunshot wound
Patellar tendon tear; difficulty in extension
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
CRPS
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

14. tx distal rectal ca
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;
Retrograde ejaculation
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

15. What is the contraindication of hyperventilation in inc ICP
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Subphrenic abscess or other abdominal abscesses; order US or CT
Strok and traumatic brain injury
Patellar tendon tear; difficulty in extension

16. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Ampicillin sublactum - pipercillin - ceftriaxone and metro

17. What is terrible triad
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
When urethral catherization is unsuccessful
Check ET tube placement if correct needle decompresion

18. How mcmurray manuver perform
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.
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

19. Indication for bariatric surgery in obese patients
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

20. When do we see complications due to hypophosphatemia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Fx displace >1mm - nonunion during followup - osteonecrosis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;

21. cat/dog bites
Amoxicillin-clavulanate
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
50%; tunneling between rectum or kin

22. midline neck swelling moves with protrusion of tongue
Seminomas
4-6 weeks for noncontact sports and longer time for contact sports
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

23. dorsiflexion and planter flexion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4-6 weeks for noncontact sports and longer time for contact sports
L5 to S2
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

24. clavicle fx
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
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
Displaced ORIF ; nondisplaced sling immobilization

25. management of nondisplaced scaphoid fx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

26. What is the strongest risk factor for male breast cancer
Patellar tendon tear; difficulty in extension
S2-S4
Klinefelter syndrome; 50 fold increase;
Brardycardia - HTN - resp depression

27. what size of ureteral stone for non op mx
Less than 5mm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Subphrenic abscess or other abdominal abscesses; order US or CT
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

28. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
Brardycardia - HTN - resp depression
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

29. several knee pain after being tackled in football game
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Brardycardia - HTN - resp depression

30. acalculus cholecystitis
Study showed no adverse effect; but they are contraindicated for PVD
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Elderly and critically ill patients

31. beta hcg and AFP
Fx displace >1mm - nonunion during followup - osteonecrosis
Elevated non seminomas
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Epi and chest compressio for prolong period of time; atropine is given after epi;

32. Incidence of AF in CABG patient

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33. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elevated non seminomas
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;

34. management of stone 8-10mm
CRPS
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

35. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Urethral stricture; pelvic of urethral trauma
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas

36. characteristics of ureteral stone?
Even after ochiopexy risk of ochiopexy higher then general population
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Klinefelter syndrome; 50 fold increase;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

37. swelling and tenderness in anterior part of knee
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
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;
Ispilateral hypoglossal nerve injury
Patellar tendon tear; difficulty in extension

38. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

39. Complications of breast impant
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Tendons more likely
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

40. When to stop raloxifene before surgery
Klinefelter syndrome; 50 fold increase;
L5 to S2
Ispilateral hypoglossal nerve injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

41. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abd pain and tenderness; bloody diarrhoea or hematochezia
When urethral catherization is unsuccessful
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

42. How to perform lachman test
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

43. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
L5 to S2
Twisting force with the foot fixed on the ground seen in football and basketball games;
CRPS

44. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Amoxicillin-clavulanate
If patient ambulatory - surgery and pain control; if not nonop mx
When urethral catherization is unsuccessful

45. suprapubic catheterization
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
When urethral catherization is unsuccessful

46. managment of animal bite in hands
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;

47. What is cushing's triad
Brardycardia - HTN - resp depression
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

48. Patient underwent CABG; postoperatively drowsy. most likely cause?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

49. differential of ultrasound finding of breast mass
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
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
S2-S4

50. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Tendons more likely
S2-S4
Patellar tendon tear; difficulty in extension