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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
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. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Nonunion and avascular necrosis; fx can block blood supply;
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. What is hungry bone syndrome?
Klinefelter syndrome; 50 fold increase;
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

3. types of hip fracture
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Less than 5mm
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

4. Why ruq calcificaion is concerning
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. How to differentiate ACL and meniscus injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Less than 5mm

6. cremasteric reflex
Strok and traumatic brain injury
Urethral stricture; pelvic of urethral trauma
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

7. most common fx when falling on outsretched hand
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Saline and silicone
24-48 hours of supportive therapy followed by cholecystectomy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

8. When do we see complications due to hypophosphatemia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;

9. diarrhoea after gastric bypass
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dumping syndrome; small and frequent meals; no simple sugar
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

10. recurrent laryngeal nerve injury
Displaced ORIF ; nondisplaced sling immobilization
Unilateral vocal cord paralysis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Klinefelter syndrome; 50 fold increase;

11. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Compression stocking - weight reduction - leg elevation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

12. Complications of breast impant
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

13. When to stop raloxifene before surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

14. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Amoxicillin-clavulanate

15. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

16. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
L5 to S2

17. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

18. varicocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

19. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
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
When urethral catherization is unsuccessful

20. SOB - confusion - petechial rash after trauma - fracture
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
S2-S4
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

21. beta hcg and AFP
Dumping syndrome; small and frequent meals; no simple sugar
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elevated non seminomas

22. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Subphrenic abscess or other abdominal abscesses; order US or CT
Compression stocking - weight reduction - leg elevation
Nonunion and avascular necrosis; fx can block blood supply;

23. How to dx ACL tear?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

24. mangement of localized lymphadenopathy
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
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dm neuropathy; stocking glove pattern

25. What is terrible triad
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Urethral stricture; pelvic of urethral trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

26. How to evaluate painless testicular swelling suspicious for cancer
Increased size during the day and valsalva means it is communicated with peritoneal cavity
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
SAH due to post communicating artery aneurysm;

27. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

28. 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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Supraglottic edema; low threshold for intubation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

29. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
CRPS

30. beta HCG
SAH due to post communicating artery aneurysm;
Progressive fibrosis of palmar fascia. etiololgy not known;
Seminomas
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

31. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
L5 to S2
Patellar tendon tear; difficulty in extension
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

32. complication displaced or communited distal radial fx
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
Carpal tunnel syndrom
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

33. several knee pain after being tackled in football game
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Dm neuropathy; stocking glove pattern
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

34. anal sphincter tone
If any compressive symptoms eg. dysphagia
10-12 months
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
S2-S4

35. common complication of inadequate mx of scaphoid fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Nonunion and avascular necrosis; fx can block blood supply;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

36. What is prehn sign?
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;
Subphrenic abscess or other abdominal abscesses; order US or CT
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Saline and silicone

37. sudden onset of postoperative hyperglycemia when patient on TPN
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Subphrenic abscess or other abdominal abscesses; order US or CT
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

38. indication of ursodeoxycholic acid
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
S2-S4
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. acalculus cholecystitis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elderly and critically ill patients
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

40. menisci injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Twisting force with the foot fixed on the ground seen in football and basketball games;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

41. management of stone 8-10mm
Patellar tendon tear; difficulty in extension
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

42. most frequent complication of TURP
Retrograde ejaculation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

43. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

44. Dupuytren contracture
Meniscus injury; medial most common; pain/swelling; popping sensation
Progressive fibrosis of palmar fascia. etiololgy not known;
Saline and silicone
Compression stocking - weight reduction - leg elevation

45. 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
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
Patellar tendon tear; difficulty in extension

46. How to differentiate communicative and non-communicative hydrocele
50%; tunneling between rectum or kin
When urethral catherization is unsuccessful
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Strok and traumatic brain injury

47. What types of breast implants are available
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Saline and silicone
Low anterior resection and radio; add chemo if node positive
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

48. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Fx displace >1mm - nonunion during followup - osteonecrosis
Next best step surgery; not ultrasound

49. stress fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Ispilateral hypoglossal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

50. first line of management of PVD
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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