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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.
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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. antibiotics of acute cholecystitis
Compression stocking - weight reduction - leg elevation
S2-S4
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Supraglottic edema; low threshold for intubation

2. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation
Dm neuropathy; stocking glove pattern
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

3. perioral numbness after parathyroidectomy
Urethral stricture; pelvic of urethral trauma
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
Tendons more likely
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

4. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Displaced ORIF ; nondisplaced sling immobilization
Epi and chest compressio for prolong period of time; atropine is given after epi;
Less than 5mm

5. What is hungry bone syndrome?
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

6. management of gunshot wound
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

7. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Patellar tendon tear; difficulty in extension

8. Can we use beta blocker for pvd?
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Study showed no adverse effect; but they are contraindicated for PVD

9. What is cushing's triad
Brardycardia - HTN - resp depression
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Twisting force with the foot fixed on the ground seen in football and basketball games;

10. Why right varicocele is more concerning?

11. Dupuytren contracture
CRPS
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Progressive fibrosis of palmar fascia. etiololgy not known;

12. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

13. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Amoxicillin-clavulanate

14. severe pain in leg after MVC
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
Mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Seminomas

15. most frequent complication of TURP
When urethral catherization is unsuccessful
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Retrograde ejaculation

16. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
ACL injury

17. diarrhoea after gastric bypass
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Dumping syndrome; small and frequent meals; no simple sugar

18. complications of TPN
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

19. How to differentiate communicative and non-communicative hydrocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Urethral stricture; pelvic of urethral trauma
Low anterior resection and radio; add chemo if node positive
Increased size during the day and valsalva means it is communicated with peritoneal cavity

20. Complications of breast impant
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

21. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Study showed no adverse effect; but they are contraindicated for PVD
CRPS
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

22. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

23. Why varicocele more common in the left side
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Displaced ORIF ; nondisplaced sling immobilization
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Progressive fibrosis of palmar fascia. etiololgy not known;

24. recurrent laryngeal nerve injury
Meniscus injury; medial most common; pain/swelling; popping sensation
Unilateral vocal cord paralysis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

25. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

26. What are the common injuries from lightning?
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

27. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

28. types of hip fracture
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

29. most common complication of acute cholecystitis
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

30. How mcmurray manuver perform
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

31. When goiter needs surgery
Tendons more likely
Ispilateral hypoglossal nerve injury
Fx displace >1mm - nonunion during followup - osteonecrosis
If any compressive symptoms eg. dysphagia

32. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

33. anal sphincter tone
S2-S4
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
15-40%; self limiting;doesn't require tx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

34. indication of ursodeoxycholic acid
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
4-6 weeks for noncontact sports and longer time for contact sports
Twisting force with the foot fixed on the ground seen in football and basketball games;

35. SOB - confusion - petechial rash after trauma - fracture
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Unilateral vocal cord paralysis
Elevated non seminomas

36. midline neck swelling moves with protrusion of tongue
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
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

37. What percent of anal abscess deveolop fisutula
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Study showed no adverse effect; but they are contraindicated for PVD
50%; tunneling between rectum or kin
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

38. How varicocele causes testicular atrophy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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. SAH due to posterior inferior cerebellar aneurysm
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Headache - ataxia - bulbar dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

40. prostate enlarged - nontender - no nodularity - elevated PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Twisting force with the foot fixed on the ground seen in football and basketball games;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

41. how ABI help dx of PVD
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

42. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If patient ambulatory - surgery and pain control; if not nonop mx
Carpal tunnel syndrom

43. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
SAH due to post communicating artery aneurysm;
Displaced ORIF ; nondisplaced sling immobilization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

44. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
24-48 hours of supportive therapy followed by cholecystectomy
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;
Meniscus injury; medial most common; pain/swelling; popping sensation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

45. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
15-40%; self limiting;doesn't require tx
ACL injury
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

46. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Epi and chest compressio for prolong period of time; atropine is given after epi;

47. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Klinefelter syndrome; 50 fold increase;
Tendons more likely

48. tx distal rectal ca
10-12 months
Meniscus injury; medial most common; pain/swelling; popping sensation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Low anterior resection and radio; add chemo if node positive

49. acalculus cholecystitis
Elderly and critically ill patients
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Saline and silicone
Fx displace >1mm - nonunion during followup - osteonecrosis

50. Tx of pulmonary contusion
Tendons more likely
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea