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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. cat/dog bites
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

2. first step for evaluation of testicular swelling
Pure motor stroke; limited neurological dysfunction
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

3. sudden onset of postoperative hyperglycemia when patient on TPN
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

4. What types of breast implants are available
Strok and traumatic brain injury
Saline and silicone
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

5. painless testicular mass in young male
Retrograde ejaculation
Malignancy until proven otherwise
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

6. How mcmurray manuver perform
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Elevated non seminomas
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

7. first line of management of PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

8. 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
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
Compression stocking - weight reduction - leg elevation
Elderly and critically ill patients

9. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Meniscus injury; medial most common; pain/swelling; popping sensation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

10. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Low anterior resection and radio; add chemo if node positive

11. mx of stress fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

12. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
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
Dumping syndrome; small and frequent meals; no simple sugar

13. 3 mo with groin bulge; bulge appears when child cries
Carpal tunnel syndrom
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

14. lacunar stroke
Dumping syndrome; small and frequent meals; no simple sugar
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pure motor stroke; limited neurological dysfunction
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

15. What is hungry bone syndrome?
When urethral catherization is unsuccessful
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

16. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Dm neuropathy; stocking glove pattern
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

17. how ABI help dx of PVD
Retrograde ejaculation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

18. 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;
If any compressive symptoms eg. dysphagia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Strok and traumatic brain injury

19. Why varicocele more common in the left side
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Ispilateral hypoglossal nerve injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

20. ipsilateral deviation of tongue upon protrusion
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ispilateral hypoglossal nerve injury
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;

21. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

22. most frequent complication of TURP
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Subphrenic abscess or other abdominal abscesses; order US or CT
Retrograde ejaculation

23. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

24. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Strok and traumatic brain injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

25. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Low anterior resection and radio; add chemo if node positive
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

26. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Study showed no adverse effect; but they are contraindicated for PVD

27. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
L5 to S2
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

28. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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

29. most common fx when falling on outsretched hand
Seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

30. diarrhoea 4-5 days after cholecystectomy
Amoxicillin-clavulanate
Abd pain and tenderness; bloody diarrhoea or hematochezia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Tendons more likely

31. dumping syndrome after gastrectomy
CRPS
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Subphrenic abscess or other abdominal abscesses; order US or CT

32. Complications of breast impant
Compression stocking - weight reduction - leg elevation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
When urethral catherization is unsuccessful
Seminomas

33. beta HCG
Patellar tendon tear; difficulty in extension
Progressive fibrosis of palmar fascia. etiololgy not known;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Seminomas

34. What percent of anal abscess deveolop fisutula
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Saline and silicone
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
50%; tunneling between rectum or kin

35. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Carpal tunnel syndrom
50%; tunneling between rectum or kin
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

36. differential of ultrasound finding of breast mass
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

37. popping sensation; rapid onset of knee effusion. athelet
Malignancy until proven otherwise
ACL injury
10-12 months
4-6 weeks for noncontact sports and longer time for contact sports

38. Indication for bariatric surgery in obese patients
Meniscus injury; medial most common; pain/swelling; popping sensation
L5 to S2
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

39. antibiotics of acute cholecystitis
15-40%; self limiting;doesn't require tx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Ampicillin sublactum - pipercillin - ceftriaxone and metro
MAT; medial meniscus injury; ACL and Tibial colateral ligament

40. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Klinefelter syndrome; 50 fold increase;
Subphrenic abscess or other abdominal abscesses; order US or CT
Study showed no adverse effect; but they are contraindicated for PVD
4-6 weeks for noncontact sports and longer time for contact sports

41. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Meniscus injury; medial most common; pain/swelling; popping sensation
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

42. inhalation of hot air - steam - smoke in burn victim
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

43. xray finding of stress fx after 3-4w
When urethral catherization is unsuccessful
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
50%; tunneling between rectum or kin
Strok and traumatic brain injury

44. surgery for acute cholecystities
Saline and silicone
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
24-48 hours of supportive therapy followed by cholecystectomy

45. Incidence of AF in CABG patient

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46. pregnant patient with asymptomatic gall stones
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
CRPS
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

47. How varicocele causes testicular atrophy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months

48. aspiration of breast cyst is bloody
Subphrenic abscess or other abdominal abscesses; order US or CT
Pure motor stroke; limited neurological dysfunction
Mammogram
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

49. What is cushing's triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Brardycardia - HTN - resp depression
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

50. 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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion