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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. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Compression stocking - weight reduction - leg elevation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

2. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Next best step surgery; not ultrasound

3. when patient with severe lung disease have C02 retention
24-48 hours of supportive therapy followed by cholecystectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

4. What time frame required for bone remodeling
10-12 months
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
L5 to S2
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

5. most frequent complication of TURP
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Retrograde ejaculation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

6. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Tendons more likely
If patient ambulatory - surgery and pain control; if not nonop mx
Meniscus injury; medial most common; pain/swelling; popping sensation

7. cremasteric reflex test?
24-48 hours of supportive therapy followed by cholecystectomy
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Epi and chest compressio for prolong period of time; atropine is given after epi;

8. popping sensation; rapid onset of knee effusion. athelet
24-48 hours of supportive therapy followed by cholecystectomy
ACL injury
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

9. Incidence of AF in CABG patient

10. What percent of anal abscess deveolop fisutula
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
50%; tunneling between rectum or kin
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

11. SAH due to posterior inferior cerebellar aneurysm
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Mammogram
Check ET tube placement if correct needle decompresion
Headache - ataxia - bulbar dysfunction

12. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
ACL injury

13. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Headache - ataxia - bulbar dysfunction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Urethral stricture; pelvic of urethral trauma
Meniscus injury; medial most common; pain/swelling; popping sensation

14. mangement of localized lymphadenopathy
Patellar tendon tear; difficulty in extension
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

15. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Carpal tunnel syndrom
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
4-6 weeks for noncontact sports and longer time for contact sports

16. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Low anterior resection and radio; add chemo if node positive

17. management of stone 8-10mm
Low anterior resection and radio; add chemo if node positive
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
Meniscus injury; medial most common; pain/swelling; popping sensation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

18. dumping syndrome after gastrectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia

19. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
When urethral catherization is unsuccessful
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. What is the strongest risk factor for male breast cancer
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
Ispilateral hypoglossal nerve injury
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
Klinefelter syndrome; 50 fold increase;

21. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Unilateral vocal cord paralysis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

22. differential of ultrasound finding of breast mass
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
S2-S4
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

23. How to confirm achiles tendon rupture
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

24. aspiration of breast cyst is bloody
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Mammogram
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

25. How to differentiate ACL and meniscus injury
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

26. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

27. first step for evaluation of testicular swelling
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
Tendons more likely
Check ET tube placement if correct needle decompresion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

28. What is prehn sign?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury

29. lacunar stroke
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Pure motor stroke; limited neurological dysfunction
15-40%; self limiting;doesn't require tx
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

30. midline neck swelling moves with protrusion of tongue
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

31. What is most common lung injury after blunt chest trauma?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Urethral stricture; pelvic of urethral trauma
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
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

32. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
4-6 weeks for noncontact sports and longer time for contact sports
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Check ET tube placement if correct needle decompresion

33. What is the contraindication of hyperventilation in inc ICP
15-40%; self limiting;doesn't require tx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Strok and traumatic brain injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

34. 27 yo with scrotal mass; warm tender testes feel like bag of worms
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. Dupuytren contracture
Next best step surgery; not ultrasound
Progressive fibrosis of palmar fascia. etiololgy not known;
Elderly and critically ill patients
Urethral stricture; pelvic of urethral trauma

36. How to manage a patient with asystole
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Epi and chest compressio for prolong period of time; atropine is given after epi;
If patient ambulatory - surgery and pain control; if not nonop mx

37. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
15-40%; self limiting;doesn't require tx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Mammogram

38. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
When urethral catherization is unsuccessful
Epi and chest compressio for prolong period of time; atropine is given after epi;

39. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Twisting force with the foot fixed on the ground seen in football and basketball games;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

40. management of nondisplaced scaphoid fx
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. ipsilateral deviation of tongue upon protrusion
Elevated non seminomas
Ispilateral hypoglossal nerve injury
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
Saline and silicone

42. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Less than 5mm
S2-S4
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

43. What types of breast implants are available
Dumping syndrome; small and frequent meals; no simple sugar
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Saline and silicone
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

44. How to dx ACL tear?
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Urethral stricture; pelvic of urethral trauma

45. SOB - confusion - petechial rash after trauma - fracture
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

46. most common complication of acute cholecystitis
Dm neuropathy; stocking glove pattern
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

47. Why ruq calcificaion is concerning
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

48. beta HCG
Seminomas
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.
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

49. When do we see complications due to hypophosphatemia
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;
Elevated non seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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

50. suprapubic catheterization
When urethral catherization is unsuccessful
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid