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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. first step for evaluation of testicular swelling
10-12 months
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;

2. xray finding of stress fx after 3-4w
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

3. painless testicular mass in young male
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Malignancy until proven otherwise
15-40%; self limiting;doesn't require tx
Low anterior resection and radio; add chemo if node positive

4. When goiter needs surgery
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If any compressive symptoms eg. dysphagia
Malignancy until proven otherwise
Even after ochiopexy risk of ochiopexy higher then general population

5. cat/dog bites
Amoxicillin-clavulanate
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
Dumping syndrome; small and frequent meals; no simple sugar
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

6. How to dx ACL tear?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
ACL 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
Retrograde ejaculation

7. management of hip fracture
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
If patient ambulatory - surgery and pain control; if not nonop mx
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

8. antibiotics of acute cholecystitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

9. most frequent complication of TURP
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Retrograde ejaculation
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
Urethral stricture; pelvic of urethral trauma

10. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

11. What percent of anal abscess deveolop fisutula
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
50%; tunneling between rectum or kin

12. Why ruq calcificaion is concerning
ACL injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Brardycardia - HTN - resp depression

13. how hyperventilation lowers ICP
When urethral catherization is unsuccessful
Fx displace >1mm - nonunion during followup - osteonecrosis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Compression stocking - weight reduction - leg elevation

14. types of hip fracture
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Progressive fibrosis of palmar fascia. etiololgy not known;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

15. first line of management of PVD
Retrograde ejaculation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elderly and critically ill patients
Urethral stricture; pelvic of urethral trauma

16. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

17. mangement of localized lymphadenopathy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Carpal tunnel syndrom
Study showed no adverse effect; but they are contraindicated for PVD

18. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Saline and silicone

19. SOB - confusion - petechial rash after trauma - fracture
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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;

20. Dupuytren contracture
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
Progressive fibrosis of palmar fascia. etiololgy not known;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Less than 5mm

21. several knee pain after being tackled in football game
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Headache - ataxia - bulbar dysfunction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

22. characteristics of ureteral stone?
When urethral catherization is unsuccessful
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

23. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
If any compressive symptoms eg. dysphagia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

24. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Supraglottic edema; low threshold for intubation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

25. popping sensation; rapid onset of knee effusion. athelet
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
ACL injury
Patellar tendon tear; difficulty in extension
MAT; medial meniscus injury; ACL and Tibial colateral ligament

26. What is cushing's triad
Brardycardia - HTN - resp depression
Fx displace >1mm - nonunion during followup - osteonecrosis
Dm neuropathy; stocking glove pattern
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

27. aspiration of breast cyst is nonbloody
SAH due to post communicating artery aneurysm;
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

28. Why right varicocele is more concerning?

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29. What is hungry bone syndrome?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Study showed no adverse effect; but they are contraindicated for PVD
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

30. How to differentiate ACL and meniscus 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
Compression stocking - weight reduction - leg elevation
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Klinefelter syndrome; 50 fold increase;

31. severe pain in leg after MVC
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
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

32. diarrhoea after gastric bypass
Dm neuropathy; stocking glove pattern
Dumping syndrome; small and frequent meals; no simple sugar
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Epi and chest compressio for prolong period of time; atropine is given after epi;

33. How to confirm achiles tendon rupture
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
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

34. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

35. When patient can go back to sports after clavicle fx
Ispilateral hypoglossal nerve injury
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
4-6 weeks for noncontact sports and longer time for contact sports

36. cremasteric reflex
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

37. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Strok and traumatic brain injury
Next best step surgery; not ultrasound
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Study showed no adverse effect; but they are contraindicated for PVD

38. pregnant patient with asymptomatic gall stones
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
SAH due to post communicating artery aneurysm;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

39. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
Supraglottic edema; low threshold for intubation
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
4-6 weeks for noncontact sports and longer time for contact sports

40. Why varicocele more common in the left side
Compression stocking - weight reduction - leg elevation
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

41. What is most common lung injury after blunt chest trauma?
Next best step surgery; not ultrasound
10-12 months
L5 to S2
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

42. contraindication of urethral catheterization
L5 to S2
10-12 months
Urethral stricture; pelvic of urethral trauma
If patient ambulatory - surgery and pain control; if not nonop mx

43. What is terrible triad
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Twisting force with the foot fixed on the ground seen in football and basketball games;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
MAT; medial meniscus injury; ACL and Tibial colateral ligament

44. when patient with severe lung disease have C02 retention
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

45. inhalation of hot air - steam - smoke in burn victim
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Retrograde ejaculation
Supraglottic edema; low threshold for intubation
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

46. Valgus and Varus tests
Saline and silicone
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression

47. perioral numbness after parathyroidectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Next best step surgery; not ultrasound
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

48. tx distal rectal ca
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

49. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Strok and traumatic brain injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

50. How to evaluate painless testicular swelling suspicious for 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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
10-12 months