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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 abd pain; ct scan neg and cardiac history; metabolic acidosis
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

2. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

3. management of stone 8-10mm
Dm neuropathy; stocking glove pattern
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
S2-S4

4. How to differentiate communicative and non-communicative hydrocele
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Check ET tube placement if correct needle decompresion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity

5. recurrent laryngeal nerve injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
SAH due to post communicating artery aneurysm;
Mammogram
Unilateral vocal cord paralysis

6. types of hip fracture
4-6 weeks for noncontact sports and longer time for contact sports
50%; tunneling between rectum or kin
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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

7. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Amoxicillin-clavulanate
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

8. How to perform lachman test
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

9. Why ruq calcificaion is concerning
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Fx displace >1mm - nonunion during followup - osteonecrosis

10. lacunar stroke
ACL injury
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;
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
Pure motor stroke; limited neurological dysfunction

11. What is the contraindication of hyperventilation in inc ICP
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

12. Valgus and Varus tests
Carpal tunnel syndrom
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

13. varicocele
Tendons more likely
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Klinefelter syndrome; 50 fold increase;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

14. complication displaced or communited distal radial fx
Retrograde ejaculation
Carpal tunnel syndrom
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
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. DD of acute scrotal pain
Retrograde ejaculation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

16. Why initial xrays are negative in scaphoid fx
Supraglottic edema; low threshold for intubation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

17. diarrhoea after gastric bypass
Fx displace >1mm - nonunion during followup - osteonecrosis
Dumping syndrome; small and frequent meals; no simple sugar
Strok and traumatic brain injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

18. How to confirm dx of compartment syndrom
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Tendons more likely
Even after ochiopexy risk of ochiopexy higher then general population

19. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
4-6 weeks for noncontact sports and longer time for contact sports

20. perioral numbness after parathyroidectomy
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

21. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

22. first step for evaluation of testicular swelling
Compression stocking - weight reduction - leg elevation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Study showed no adverse effect; but they are contraindicated for PVD

23. lacerated wound in palmer surface of hand. what structure is injured?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Tendons more likely
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pure motor stroke; limited neurological dysfunction

24. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

25. How to differentiate ACL and meniscus injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Less than 5mm

26. 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
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
4-6 weeks for noncontact sports and longer time for contact sports

27. most frequent complication of TURP
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
24-48 hours of supportive therapy followed by 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

28. management of nondisplaced scaphoid fx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
24-48 hours of supportive therapy followed by cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

29. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Supraglottic edema; low threshold for intubation
Meniscus injury; medial most common; pain/swelling; popping sensation
Pure motor stroke; limited neurological dysfunction
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

30. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Twisting force with the foot fixed on the ground seen in football and basketball games;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

31. surgery for acute cholecystities
Klinefelter syndrome; 50 fold increase;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
24-48 hours of supportive therapy followed by cholecystectomy

32. ct scan; cystic lesion in head of pancreas; next step
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;

33. When goiter needs surgery
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
L5 to S2
If any compressive symptoms eg. dysphagia
Nonunion and avascular necrosis; fx can block blood supply;

34. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

35. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

36. acalculus cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Compression stocking - weight reduction - leg elevation
If any compressive symptoms eg. dysphagia
Elderly and critically ill patients

37. Patient underwent CABG; postoperatively drowsy. most likely cause?
Urethral stricture; pelvic of urethral trauma
Less than 5mm
S2-S4
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

38. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
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

39. popping sensation; rapid onset of knee effusion. athelet
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months
ACL injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

40. midline neck swelling moves with protrusion of tongue
Twisting force with the foot fixed on the ground seen in football and basketball games;
Meniscus injury; medial most common; pain/swelling; popping sensation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

41. 3 mo with groin bulge; bulge appears when child cries
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;
If any compressive symptoms eg. dysphagia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

42. xray finding of stress fx after 3-4w
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Displaced ORIF ; nondisplaced sling immobilization

43. What is the complications of undescended testis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;
15-40%; self limiting;doesn't require tx
Even after ochiopexy risk of ochiopexy higher then general population

44. Most common of sudden death due to steering wheel injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive

45. stress fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
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

46. menisci injury
Strok and traumatic brain injury
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
Nonunion and avascular necrosis; fx can block blood supply;
Twisting force with the foot fixed on the ground seen in football and basketball games;

47. What is hungry bone syndrome?
Retrograde ejaculation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Twisting force with the foot fixed on the ground seen in football and basketball games;

48. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
CRPS
Pure motor stroke; limited neurological dysfunction
Elderly and critically ill patients

49. What is most common lung injury after blunt chest trauma?
Elderly and critically ill patients
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

50. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dumping syndrome; small and frequent meals; no simple sugar