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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. severe pain in leg after MVC
SAH due to post communicating artery aneurysm;
ACL injury
Compression stocking - weight reduction - leg elevation
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

2. Tx of proximal non metastatic rectal ca
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Low anterior resection and radio; add chemo if node positive
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

3. How to manage obesity
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

4. When do we see complications due to hypophosphatemia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

5. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Displaced ORIF ; nondisplaced sling immobilization
Elevated non seminomas
Meniscus injury; medial most common; pain/swelling; popping sensation
Progressive fibrosis of palmar fascia. etiololgy not known;

6. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Klinefelter syndrome; 50 fold increase;
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
Subphrenic abscess or other abdominal abscesses; order US or CT
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

7. perioral numbness after parathyroidectomy
Klinefelter syndrome; 50 fold increase;
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
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

8. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Low anterior resection and radio; add chemo if node positive
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

9. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Check ET tube placement if correct needle decompresion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

10. inhalation of hot air - steam - smoke in burn victim
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Supraglottic edema; low threshold for intubation
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

11. conservative Tx of varicose veins
Next best step surgery; not ultrasound
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;
Compression stocking - weight reduction - leg elevation
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

12. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Compression stocking - weight reduction - leg elevation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Even after ochiopexy risk of ochiopexy higher then general population

13. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;

14. How to manage a patient with asystole
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Epi and chest compressio for prolong period of time; atropine is given after epi;
Mammogram

15. tx distal rectal ca
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Tendons more likely
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

16. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Increased size during the day and valsalva means it is communicated with peritoneal cavity
L5 to S2

17. painless testicular mass in young male
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
L5 to S2
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Malignancy until proven otherwise

18. What is the strongest risk factor for male breast cancer
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Klinefelter syndrome; 50 fold increase;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

19. How mcmurray manuver perform
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Nonunion and avascular necrosis; fx can block blood supply;

20. complication displaced or communited distal radial fx
S2-S4
Elevated non seminomas
Carpal tunnel syndrom
Amoxicillin-clavulanate

21. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

22. Can we use beta blocker for pvd?
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Study showed no adverse effect; but they are contraindicated for PVD

23. management of nondisplaced scaphoid fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Malignancy until proven otherwise
Carpal tunnel syndrom
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

24. 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.
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

25. antibiotics of acute cholecystitis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Supraglottic edema; low threshold for intubation

26. Why right varicocele is more concerning?

27. How to dx ACL tear?
Meniscus injury; medial most common; pain/swelling; popping sensation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
CRPS
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

28. When to stop raloxifene before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

29. diarrhoea after gastric bypass
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dumping syndrome; small and frequent meals; no simple sugar
Strok and traumatic brain injury

30. Dupuytren contracture
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Progressive fibrosis of palmar fascia. etiololgy not known;
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

31. beta HCG
Epi and chest compressio for prolong period of time; atropine is given after epi;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Seminomas
Nonunion and avascular necrosis; fx can block blood supply;

32. mx of stress fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
S2-S4
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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;

33. Why initial xrays are negative in scaphoid fx
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Brardycardia - HTN - resp depression

34. most frequent complication of TURP
Retrograde ejaculation
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

35. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Saline and silicone
Dumping syndrome; small and frequent meals; no simple sugar
Abd pain and tenderness; bloody diarrhoea or hematochezia

36. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

37. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Brardycardia - HTN - resp depression

38. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Displaced ORIF ; nondisplaced sling immobilization
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dumping syndrome; small and frequent meals; no simple sugar

39. anal sphincter tone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
S2-S4

40. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Retrograde ejaculation
Carpal tunnel syndrom
Check ET tube placement if correct needle decompresion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

41. midline neck swelling moves with protrusion of tongue
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dumping syndrome; small and frequent meals; no simple sugar
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

42. 3 mo with groin bulge; bulge appears when child cries
Check ET tube placement if correct needle decompresion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
24-48 hours of supportive therapy followed by cholecystectomy

43. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
24-48 hours of supportive therapy followed by cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

44. SOB - confusion - petechial rash after trauma - fracture
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ispilateral hypoglossal nerve injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

45. popping sensation; rapid onset of knee effusion. athelet
10-12 months
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
ACL injury

46. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
S2-S4
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
10-12 months

47. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
L5 to S2

48. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

49. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
L5 to S2
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

50. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;