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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. Why initial xrays are negative in scaphoid fx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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. How to dx ACL tear?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
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;
SAH due to post communicating artery aneurysm;

3. management of stone 8-10mm
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
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

4. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Seminomas

5. acute colonic ischemia
Ispilateral hypoglossal nerve 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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

6. most common complication of acute cholecystitis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

7. painless testicular mass in young male
Malignancy until proven otherwise
Ispilateral hypoglossal nerve injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Patellar tendon tear; difficulty in extension

8. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

9. What is prehn sign?
Even after ochiopexy risk of ochiopexy higher then general population
Pure motor stroke; limited neurological dysfunction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

10. 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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

11. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

12. most frequent complication of TURP
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive
Elevated non seminomas
Progressive fibrosis of palmar fascia. etiololgy not known;

13. lacunar stroke
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

14. What is most common lung injury after blunt chest trauma?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Klinefelter syndrome; 50 fold increase;
Amoxicillin-clavulanate

15. what size of ureteral stone for non op mx
Less than 5mm
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;
24-48 hours of supportive therapy followed by cholecystectomy
Brardycardia - HTN - resp depression

16. swelling and tenderness in anterior part of knee
If any compressive symptoms eg. dysphagia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Patellar tendon tear; difficulty in extension
Unilateral vocal cord paralysis

17. When do we see complications due to hypophosphatemia
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
ACL injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

18. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Carpal tunnel syndrom
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;

19. How to confirm dx of compartment syndrom
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elderly and critically ill patients

20. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
15-40%; self limiting;doesn't require tx
Meniscus injury; medial most common; pain/swelling; popping sensation
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

21. recurrent laryngeal nerve injury
Study showed no adverse effect; but they are contraindicated for PVD
10-12 months
Unilateral vocal cord paralysis
Pure motor stroke; limited neurological dysfunction

22. Tx of proximal non metastatic rectal ca
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
When urethral catherization is unsuccessful
Low anterior resection and radio; add chemo if node positive

23. beta HCG
Headache - ataxia - bulbar dysfunction
Unilateral vocal cord paralysis
Brardycardia - HTN - resp depression
Seminomas

24. When to stop raloxifene before surgery
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

25. What is the complications of undescended testis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Urethral stricture; pelvic of urethral trauma
Even after ochiopexy risk of ochiopexy higher then general population
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

26. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
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
10-12 months
S2-S4

27. Why ruq calcificaion is concerning
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

28. transrectal prostate biopsy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis

29. Incidence of AF in CABG patient

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30. tx distal rectal ca
Supraglottic edema; low threshold for intubation
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;

31. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Displaced ORIF ; nondisplaced sling immobilization
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

32. first line of management of PVD
Carpal tunnel syndrom
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

33. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

34. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
50%; tunneling between rectum or kin
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

35. ipsilateral deviation of tongue upon protrusion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Ispilateral hypoglossal nerve injury
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
50%; tunneling between rectum or kin

36. xray finding of stress fx after 3-4w
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
Amoxicillin-clavulanate
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

37. Indication for bariatric surgery in obese patients
Tendons more likely
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
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

38. DD of acute scrotal pain
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
When urethral catherization is unsuccessful
Malignancy until proven otherwise

39. suprapubic catheterization
When urethral catherization is unsuccessful
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Less than 5mm

40. beta hcg and AFP
Meniscus injury; medial most common; pain/swelling; popping sensation
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Elevated non seminomas

41. scrotal trauma
Next best step surgery; not ultrasound
Strok and traumatic brain injury
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
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;

42. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Patellar tendon tear; difficulty in extension
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;
Subphrenic abscess or other abdominal abscesses; order US or CT
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

43. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Mammogram
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
10-12 months
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

44. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Tendons more likely

45. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Twisting force with the foot fixed on the ground seen in football and basketball games;

46. 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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
50%; tunneling between rectum or kin
Brardycardia - HTN - resp depression

47. What is hungry bone syndrome?
S2-S4
Seminomas
Less than 5mm
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

48. How to manage obesity
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

49. What is cushing's triad
Brardycardia - HTN - resp depression
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cystic scrotal fluid collection between parietal and visceral layers of testis

50. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Pure motor stroke; limited neurological dysfunction