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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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
24-48 hours of supportive therapy followed by cholecystectomy

2. Complications of breast impant
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

3. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Strok and traumatic brain injury
Even after ochiopexy risk of ochiopexy higher then general population

4. first step for evaluation of testicular swelling
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

5. 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
24-48 hours of supportive therapy followed by cholecystectomy
Klinefelter syndrome; 50 fold increase;
Ispilateral hypoglossal nerve injury

6. diarrhoea 4-5 days after cholecystectomy
S2-S4
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Unilateral vocal cord paralysis

7. first line of management of PVD
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elevated non seminomas
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

8. acalculus cholecystitis
Tendons more likely
Elderly and critically ill patients
Progressive fibrosis of palmar fascia. etiololgy not known;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

9. varicose veins with ulcer - bleeding and thrombophlebitits
CRPS
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint 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;

10. How to differentiate communicative and non-communicative hydrocele
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;
Retrograde ejaculation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

11. Patient underwent CABG; postoperatively drowsy. most likely cause?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Elevated non seminomas
Dumping syndrome; small and frequent meals; no simple sugar

12. What is the complications of undescended testis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Even after ochiopexy risk of ochiopexy higher then general population
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
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;

13. Most common of sudden death due to steering wheel injury
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

14. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
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

15. complication displaced or communited distal radial fx
Dumping syndrome; small and frequent meals; no simple sugar
Dm neuropathy; stocking glove pattern
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
Carpal tunnel syndrom

16. 3 mo with groin bulge; bulge appears when child cries
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

17. aspiration of breast cyst is nonbloody
Next best step surgery; not ultrasound
Compression stocking - weight reduction - leg elevation
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

18. scrotal trauma
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Next best step surgery; not ultrasound

19. 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.
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

20. When goiter needs surgery
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elderly and critically ill patients
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If any compressive symptoms eg. dysphagia

21. Tx of proximal non metastatic rectal ca
MAT; medial meniscus injury; ACL and Tibial colateral ligament
When urethral catherization is unsuccessful
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Low anterior resection and radio; add chemo if node positive

22. dorsiflexion and planter flexion
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Meniscus injury; medial most common; pain/swelling; popping sensation
L5 to S2

23. popping sensation; rapid onset of knee effusion. athelet
Meniscus injury; medial most common; pain/swelling; popping sensation
ACL injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

24. anal sphincter tone
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
S2-S4

25. ipsilateral deviation of tongue upon protrusion
If patient ambulatory - surgery and pain control; if not nonop mx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Compression stocking - weight reduction - leg elevation
Ispilateral hypoglossal nerve injury

26. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Check ET tube placement if correct needle decompresion
Headache - ataxia - bulbar dysfunction
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

27. aspiration of breast cyst is bloody
Ispilateral hypoglossal nerve injury
Mammogram
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fx displace >1mm - nonunion during followup - osteonecrosis

28. types of hip fracture
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;
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

29. What is the strongest risk factor for male breast cancer
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
Saline and silicone
Klinefelter syndrome; 50 fold increase;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

30. clavicle fx
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
Displaced ORIF ; nondisplaced sling immobilization
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

31. tx distal rectal ca
Supraglottic edema; low threshold for intubation
Patellar tendon tear; difficulty in extension
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sphincter sparing surgery (local resection) - abdomnio perineal resection

32. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Supraglottic edema; low threshold for intubation
Klinefelter syndrome; 50 fold increase;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

33. Why initial xrays are negative in scaphoid 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
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

34. Can we use beta blocker for pvd?
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Study showed no adverse effect; but they are contraindicated for PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

35. How mcmurray manuver perform
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Supraglottic edema; low threshold for intubation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fx displace >1mm - nonunion during followup - osteonecrosis

36. cremasteric reflex test?
4-6 weeks for noncontact sports and longer time for contact sports
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

37. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
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
10-12 months
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

38. Incidence of AF in CABG patient

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39. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Ampicillin sublactum - pipercillin - ceftriaxone and metro
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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;

40. Valgus and Varus tests
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Abd pain and tenderness; bloody diarrhoea or hematochezia

41. management of gunshot wound
L5 to S2
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

42. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

43. What is terrible triad
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Progressive fibrosis of palmar fascia. etiololgy not known;

44. What is prehn sign?
Strok and traumatic brain injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

45. conservative Tx of varicose veins
L5 to S2
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Compression stocking - weight reduction - leg elevation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Amoxicillin-clavulanate
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
Check ET tube placement if correct needle decompresion

47. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Supraglottic edema; low threshold for intubation
Displaced ORIF ; nondisplaced sling immobilization
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

48. varicocele
Saline and silicone
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

49. When do we see complications due to hypophosphatemia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

50. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;
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
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