Test your basic knowledge |

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. What is hungry bone syndrome?
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
24-48 hours of supportive therapy followed by cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Patellar tendon tear; difficulty in extension
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

3. differential of ultrasound finding of breast mass
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

4. How to confirm dx of compartment syndrom
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

5. When to do surgery in undesceneded testis?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation
Less than 5mm
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

6. SAH due to posterior inferior cerebellar aneurysm
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Urethral stricture; pelvic of urethral trauma
Headache - ataxia - bulbar dysfunction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

7. how ABI help dx of PVD
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

8. Complications of breast impant
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dumping syndrome; small and frequent meals; no simple sugar
Urethral stricture; pelvic of urethral trauma
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

9. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

10. What is most common lung injury after blunt chest trauma?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Supraglottic edema; low threshold for intubation

11. management of gunshot wound
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

12. inhalation of hot air - steam - smoke in burn victim
Cystic scrotal fluid collection between parietal and visceral layers of testis
Next best step surgery; not ultrasound
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation

13. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Compression stocking - weight reduction - leg elevation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

14. How to differentiate communicative and non-communicative hydrocele
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Patellar tendon tear; difficulty in extension
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

15. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Saline and silicone
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

16. transrectal prostate biopsy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If any compressive symptoms eg. dysphagia

17. What types of breast implants are available
24-48 hours of supportive therapy followed by cholecystectomy
Saline and silicone
If patient ambulatory - surgery and pain control; if not nonop mx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

18. anal sphincter tone
S2-S4
Even after ochiopexy risk of ochiopexy higher then general population
ACL injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

19. first step for evaluation of testicular swelling
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
SAH due to post communicating artery aneurysm;

20. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

21. What is the complications of undescended testis
ACL injury
Even after ochiopexy risk of ochiopexy higher then general population
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

22. what size of ureteral stone for non op mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Unilateral vocal cord paralysis
Less than 5mm
10-12 months

23. suprapubic catheterization
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;
When urethral catherization is unsuccessful
24-48 hours of supportive therapy followed by cholecystectomy
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

24. SOB - confusion - petechial rash after trauma - fracture
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

25. DD of acute scrotal pain
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Nonunion and avascular necrosis; fx can block blood supply;

26. How to differentiate ACL and meniscus injury
When urethral catherization is unsuccessful
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Low anterior resection and radio; add chemo if node positive
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. ipsilateral deviation of tongue upon protrusion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ispilateral hypoglossal nerve injury
Malignancy until proven otherwise
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

28. ct scan; cystic lesion in head of pancreas; next step
Patellar tendon tear; difficulty in extension
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

29. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate

30. mx of stress fx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Klinefelter syndrome; 50 fold increase;
Low anterior resection and radio; add chemo if node positive

31. What is cushing's triad
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Brardycardia - HTN - resp depression
Dm neuropathy; stocking glove pattern
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

32. dorsiflexion and planter flexion
L5 to S2
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 mesenteric ishemia; most SMA occlusion secondary to an embolism
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

33. How to confirm achiles tendon rupture
S2-S4
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
Next best step surgery; not ultrasound
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

34. several knee pain after being tackled in football game
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

35. mangement of localized lymphadenopathy
Dumping syndrome; small and frequent meals; no simple sugar
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Retrograde ejaculation
Seminomas

36. first line of management of 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
24-48 hours of supportive therapy followed by cholecystectomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

37. most common fx when falling on outsretched hand
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Subphrenic abscess or other abdominal abscesses; order US or CT
24-48 hours of supportive therapy followed by cholecystectomy

38. common complication of inadequate mx of scaphoid fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If patient ambulatory - surgery and pain control; if not nonop mx
Even after ochiopexy risk of ochiopexy higher then general population
Nonunion and avascular necrosis; fx can block blood supply;

39. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS
Nonunion and avascular necrosis; fx can block blood supply;

40. sudden onset of postoperative hyperglycemia when patient on TPN
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
L5 to S2
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

41. types of hip fracture
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Urethral stricture; pelvic of urethral trauma

42. What is the strongest risk factor for male breast cancer
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
L5 to S2
Klinefelter syndrome; 50 fold increase;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

43. 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
Klinefelter syndrome; 50 fold increase;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

44. Can we use beta blocker for pvd?
Less than 5mm
Study showed no adverse effect; but they are contraindicated for PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

45. Tx of proximal non metastatic rectal ca
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Low anterior resection and radio; add chemo if node positive

46. How to evaluate painless testicular swelling suspicious for cancer
Cystic scrotal fluid collection between parietal and visceral layers of testis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

47. How to manage obesity
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

48. Why varicocele more common in the left side
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Headache - ataxia - bulbar dysfunction
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

49. Why initial xrays are negative in scaphoid fx
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
Patellar tendon tear; difficulty in extension
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

50. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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