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 most common lung injury after blunt chest trauma?
Fx displace >1mm - nonunion during followup - osteonecrosis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
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;

2. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Study showed no adverse effect; but they are contraindicated for PVD
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

3. How to manage a patient with asystole
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Epi and chest compressio for prolong period of time; atropine is given after epi;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

4. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Dm neuropathy; stocking glove pattern
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

5. What is hungry bone syndrome?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

6. When goiter needs surgery
Malignancy until proven otherwise
If any compressive symptoms eg. dysphagia
Urethral stricture; pelvic of urethral trauma
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

7. common complication of inadequate mx of scaphoid fx
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
Unilateral vocal cord paralysis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

8. prostate enlarged - nontender - no nodularity - elevated PSA
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Check ET tube placement if correct needle decompresion

9. Most common of sudden death due to steering wheel injury
Study showed no adverse effect; but they are contraindicated for PVD
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;

10. complication displaced or communited distal radial fx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Carpal tunnel syndrom
Progressive fibrosis of palmar fascia. etiololgy not known;

11. 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
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
Fx displace >1mm - nonunion during followup - osteonecrosis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

12. recurrent laryngeal nerve injury
Dumping syndrome; small and frequent meals; no simple sugar
Cystic scrotal fluid collection between parietal and visceral layers of testis
Unilateral vocal cord paralysis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

13. aspiration of breast cyst is nonbloody
10-12 months
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
CRPS
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

14. swelling and tenderness in anterior part of knee
Elderly and critically ill patients
Patellar tendon tear; difficulty in extension
10-12 months
50%; tunneling between rectum or kin

15. menisci injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Twisting force with the foot fixed on the ground seen in football and basketball games;

16. conservative Tx of varicose veins
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Compression stocking - weight reduction - leg elevation
Ispilateral hypoglossal nerve injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

17. What is terrible triad
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
SAH due to post communicating artery aneurysm;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

18. SOB - confusion - petechial rash after trauma - fracture
Pure motor stroke; limited neurological dysfunction
Low anterior resection and radio; add chemo if node positive
If any compressive symptoms eg. dysphagia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

19. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Patellar tendon tear; difficulty in extension
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

20. varicose veins with ulcer - bleeding and thrombophlebitits
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Carpal tunnel syndrom

21. several knee pain after being tackled in football game
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Subphrenic abscess or other abdominal abscesses; order US or CT
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Amoxicillin-clavulanate

22. severe pain in leg after MVC
Saline and silicone
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

23. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
<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
Strok and traumatic brain injury

24. antibiotics of acute cholecystitis
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
Saline and silicone
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Ampicillin sublactum - pipercillin - ceftriaxone and metro

25. 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
Supraglottic edema; low threshold for intubation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Carpal tunnel syndrom

26. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elderly and critically ill patients
Amoxicillin-clavulanate
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

27. cat/dog bites
ACL injury
S2-S4
Amoxicillin-clavulanate
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

28. SAH due to posterior inferior cerebellar aneurysm
Retrograde ejaculation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
Headache - ataxia - bulbar dysfunction

29. Why varicocele more common in the left side
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Less than 5mm

30. 3 mo with groin bulge; bulge appears when child cries
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
10-12 months

31. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Retrograde ejaculation
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

32. types of hip fracture
Nonunion and avascular necrosis; fx can block blood supply;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

33. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Elderly and critically ill patients
Supraglottic edema; low threshold for intubation
CRPS
S2-S4

34. aspiration of breast cyst is bloody
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
10-12 months
Mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

35. Incidence of AF in CABG patient

36. When do we see complications due to hypophosphatemia
Even after ochiopexy risk of ochiopexy higher then general population
Unilateral vocal cord paralysis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;

37. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

38. What is cushing's triad
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Brardycardia - HTN - resp depression

39. painless testicular mass in young male
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Malignancy until proven otherwise

40. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

41. acalculus cholecystitis
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elderly and critically ill patients
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

42. How to perform lachman test
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
10-12 months
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

43. Indication for bariatric surgery in obese patients
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective 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;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

44. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation
Klinefelter syndrome; 50 fold increase;

45. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
MAT; medial meniscus injury; ACL and Tibial colateral ligament

46. management of gunshot wound
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive

47. Can we use beta blocker for pvd?
Dm neuropathy; stocking glove pattern
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
Study showed no adverse effect; but they are contraindicated for PVD
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

48. surgery for acute cholecystities
Next best step surgery; not ultrasound
Cystic scrotal fluid collection between parietal and visceral layers of testis
24-48 hours of supportive therapy followed by cholecystectomy
When urethral catherization is unsuccessful

49. popping sensation; rapid onset of knee effusion. athelet
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
ACL injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

50. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dm neuropathy; stocking glove pattern
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Check ET tube placement if correct needle decompresion