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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. What is the contraindication of hyperventilation in inc ICP
Study showed no adverse effect; but they are contraindicated for PVD
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
L5 to S2
Strok and traumatic brain injury

2. ipsilateral deviation of tongue upon protrusion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ispilateral hypoglossal nerve injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dumping syndrome; small and frequent meals; no simple sugar

3. 3 mo with groin bulge; bulge appears when child cries
Brardycardia - HTN - resp depression
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

4. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Twisting force with the foot fixed on the ground seen in football and basketball games;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

5. Can we use beta blocker for pvd?
If any compressive symptoms eg. dysphagia
Displaced ORIF ; nondisplaced sling immobilization
Study showed no adverse effect; but they are contraindicated for PVD
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

6. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

7. Dupuytren contracture
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Brardycardia - HTN - resp depression
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
Progressive fibrosis of palmar fascia. etiololgy not known;

8. first line of management of PVD
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

9. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

10. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Meniscus injury; medial most common; pain/swelling; popping sensation

11. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

12. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dm neuropathy; stocking glove pattern
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

13. How varicocele causes testicular atrophy
Saline and silicone
Mammogram
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

14. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile 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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Tendons more likely

15. 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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Brardycardia - HTN - resp depression

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

17. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
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
Malignancy until proven otherwise
Progressive fibrosis of palmar fascia. etiololgy not known;

18. SOB - confusion - petechial rash after trauma - fracture
Less than 5mm
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

19. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

20. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Elderly and critically ill patients
Subphrenic abscess or other abdominal abscesses; order US or CT
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;

21. management of hip fracture
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
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

22. acute colonic ischemia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Abd pain and tenderness; bloody diarrhoea or hematochezia

23. What is terrible triad
When urethral catherization is unsuccessful
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abd pain and tenderness; bloody diarrhoea or hematochezia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

24. Valgus and Varus tests
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

25. What is prehn sign?
When urethral catherization is unsuccessful
CRPS
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

26. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Compression stocking - weight reduction - leg elevation
Next best step surgery; not ultrasound

27. ct scan; cystic lesion in head of pancreas; next step
Tendons more likely
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
50%; tunneling between rectum or kin
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

28. mx of stress fx
CRPS
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Saline and silicone

29. diarrhoea after gastric bypass
Tendons more likely
24-48 hours of supportive therapy followed by cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dumping syndrome; small and frequent meals; no simple sugar

30. Tx of proximal non metastatic rectal ca
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Low anterior resection and radio; add chemo if node positive
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

31. Indication for bariatric surgery in obese patients
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
24-48 hours of supportive therapy followed by cholecystectomy

32. anal sphincter tone
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
S2-S4
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

33. lacunar stroke
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pure motor stroke; limited neurological dysfunction

34. complications of TPN
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Klinefelter syndrome; 50 fold increase;

35. suprapubic catheterization
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
When urethral catherization is unsuccessful
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

36. Incidence of AF in CABG patient

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37. differential of ultrasound finding of breast mass
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
SAH due to post communicating artery aneurysm;
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
Elevated non seminomas

38. What time frame required for bone remodeling
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
10-12 months

39. Why right varicocele is more concerning?

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40. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
15-40%; self limiting;doesn't require tx

41. management of gunshot wound
Seminomas
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
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

42. How to differentiate ACL and meniscus injury
When urethral catherization is unsuccessful
Progressive fibrosis of palmar fascia. etiololgy not known;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

43. Why varicocele more common in the left side
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

44. How to dx ACL tear?
If any compressive symptoms eg. dysphagia
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Retrograde ejaculation
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

45. xray finding of stress fx after 3-4w
S2-S4
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

46. managment of animal bite in hands
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

47. 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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

48. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Low anterior resection and radio; add chemo if node positive
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

49. Tx of pulmonary contusion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Malignancy until proven otherwise

50. When to stop raloxifene before surgery
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx