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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. Patient underwent CABG; postoperatively drowsy. most likely cause?
Strok and traumatic brain injury
Compression stocking - weight reduction - leg elevation
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

2. antibiotics of acute cholecystitis
Elevated non seminomas
Nonunion and avascular necrosis; fx can block blood supply;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

3. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased size during the day and valsalva means it is communicated with peritoneal cavity

4. painless testicular mass in young male
Nonunion and avascular necrosis; fx can block blood supply;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Patellar tendon tear; difficulty in extension
Malignancy until proven otherwise

5. inhalation of hot air - steam - smoke in burn victim
Unilateral vocal cord paralysis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Supraglottic edema; low threshold for intubation

6. When do we see complications due to hypophosphatemia
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mammogram
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. Tx of proximal non metastatic rectal ca
Amoxicillin-clavulanate
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Low anterior resection and radio; add chemo if node positive

8. dumping syndrome after gastrectomy
Amoxicillin-clavulanate
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

9. common complication of inadequate mx of scaphoid fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Nonunion and avascular necrosis; fx can block blood supply;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevated non seminomas

10. complication displaced or communited distal radial fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If any compressive symptoms eg. dysphagia
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
Carpal tunnel syndrom

11. management of hip fracture
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If patient ambulatory - surgery and pain control; if not nonop mx
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia

12. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Patellar tendon tear; difficulty in extension
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

13. What types of breast implants are available
Saline and silicone
SAH due to post communicating artery aneurysm;
Displaced ORIF ; nondisplaced sling immobilization
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

14. management of nondisplaced scaphoid fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

15. management of gunshot wound
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
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

16. How to perform lachman test
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Cystic scrotal fluid collection between parietal and visceral layers of testis

17. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dm neuropathy; stocking glove pattern
15-40%; self limiting;doesn't require tx

18. How to differentiate communicative and non-communicative hydrocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Progressive fibrosis of palmar fascia. etiololgy not known;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Supraglottic edema; low threshold for intubation

19. acute colonic ischemia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Malignancy until proven otherwise
Abd pain and tenderness; bloody diarrhoea or hematochezia
Even after ochiopexy risk of ochiopexy higher then general population

20. What is hydrocele?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dm neuropathy; stocking glove pattern
Check ET tube placement if correct needle decompresion
Cystic scrotal fluid collection between parietal and visceral layers of testis

21. clavicle fx
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Displaced ORIF ; nondisplaced sling immobilization

22. xray finding of stress fx after 3-4w
Malignancy until proven otherwise
Dm neuropathy; stocking glove pattern
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

23. what size of ureteral stone for non op mx
Even after ochiopexy risk of ochiopexy higher then general population
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If any compressive symptoms eg. dysphagia
Less than 5mm

24. What is the contraindication of hyperventilation in inc ICP
Check ET tube placement if correct needle decompresion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Strok and traumatic brain injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
10-12 months
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

26. When to stop raloxifene before surgery
Malignancy until proven otherwise
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

27. ct scan; cystic lesion in head of pancreas; next step
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Tendons more likely
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

28. first step for evaluation of testicular swelling
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If patient ambulatory - surgery and pain control; if not nonop mx
Nonunion and avascular necrosis; fx can block blood supply;

29. lacerated wound in palmer surface of hand. what structure is injured?
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
Tendons more likely
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;
Dumping syndrome; small and frequent meals; no simple sugar

30. beta hcg and AFP
Mammogram
Elevated non seminomas
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

31. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Next best step surgery; not ultrasound

32. What is prehn sign?
Tendons more likely
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

33. How varicocele causes testicular atrophy
Amoxicillin-clavulanate
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Next best step surgery; not ultrasound
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

34. 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
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

35. What is the strongest risk factor for male breast cancer
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Klinefelter syndrome; 50 fold increase;
Progressive fibrosis of palmar fascia. etiololgy not known;

36. several knee pain after being tackled in football game
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Displaced ORIF ; nondisplaced sling immobilization
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Abd pain and tenderness; bloody diarrhoea or hematochezia

37. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
ACL injury
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma

38. 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
4-6 weeks for noncontact sports and longer time for contact sports
CRPS
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

39. Incidence of AF in CABG patient

40. cat/dog bites
Check ET tube placement if correct needle decompresion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Amoxicillin-clavulanate
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

41. DD of acute scrotal pain
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

42. managment of animal bite in hands
Brardycardia - HTN - resp depression
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;
Next best step surgery; not ultrasound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

43. anal sphincter tone
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Epi and chest compressio for prolong period of time; atropine is given after epi;
S2-S4

44. How to dx ACL tear?
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

45. Tx of pulmonary contusion
When urethral catherization is unsuccessful
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

46. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Amoxicillin-clavulanate
When urethral catherization is unsuccessful
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

47. severe pain in leg after MVC
Dumping syndrome; small and frequent meals; no simple sugar
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Next best step surgery; not ultrasound
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

48. aspiration of breast cyst is nonbloody
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Elevated non seminomas

49. contraindication of urethral catheterization
Brardycardia - HTN - resp depression
Urethral stricture; pelvic of urethral trauma
Unilateral vocal cord paralysis
Pure motor stroke; limited neurological dysfunction

50. What is terrible triad
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Ispilateral hypoglossal nerve injury