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?
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

2. recurrent laryngeal nerve injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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

3. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
SAH due to post communicating artery aneurysm;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Supraglottic edema; low threshold for intubation

4. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Strok and traumatic brain injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
L5 to S2

5. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

6. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Strok and traumatic brain injury
Unilateral vocal cord paralysis
Check ET tube placement if correct needle decompresion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

7. menisci injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abd pain and tenderness; bloody diarrhoea or hematochezia
Twisting force with the foot fixed on the ground seen in football and basketball games;
50%; tunneling between rectum or kin

8. beta hcg and AFP
Headache - ataxia - bulbar dysfunction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevated non seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

9. aspiration of breast cyst is bloody
Mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Supraglottic edema; low threshold for intubation
Check ET tube placement if correct needle decompresion

10. diarrhoea after gastric bypass
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound

11. What time frame required for bone remodeling
Dumping syndrome; small and frequent meals; no simple sugar
Tendons more likely
Cystic scrotal fluid collection between parietal and visceral layers of testis
10-12 months

12. Indication for bariatric surgery in obese patients
Malignancy until proven otherwise
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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;

13. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
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;

14. differential of ultrasound finding of breast mass
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Compression stocking - weight reduction - leg elevation
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

15. varicocele
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If any compressive symptoms eg. dysphagia

16. characteristics of ureteral stone?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Seminomas
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

17. How to confirm achiles tendon rupture
Compression stocking - weight reduction - leg elevation
Headache - ataxia - bulbar dysfunction
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

18. complications of TPN
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Low anterior resection and radio; add chemo if node positive
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

19. When to stop raloxifene before surgery
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Even after ochiopexy risk of ochiopexy higher then general population
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

20. conservative Tx of varicose veins
Retrograde ejaculation
Compression stocking - weight reduction - leg elevation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mammogram

21. What types of breast implants are available
Pure motor stroke; limited neurological dysfunction
Saline and silicone
Supraglottic edema; low threshold for intubation
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;

22. Most common of sudden death due to steering wheel injury
Retrograde ejaculation
Twisting force with the foot fixed on the ground seen in football and basketball games;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

23. What is hydrocele?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cystic scrotal fluid collection between parietal and visceral layers of testis

24. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. beta HCG
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Seminomas

26. acute colonic ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Subphrenic abscess or other abdominal abscesses; order US or CT

27. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

28. perioral numbness after parathyroidectomy
Headache - ataxia - bulbar dysfunction
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ispilateral hypoglossal nerve injury

29. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Ispilateral hypoglossal nerve injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

30. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

31. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Patellar tendon tear; difficulty in extension
ACL 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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

32. How to dx ACL tear?
Dumping syndrome; small and frequent meals; no simple sugar
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
S2-S4
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

33. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dumping syndrome; small and frequent meals; no simple sugar
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
Next best step surgery; not ultrasound

34. aspiration of breast cyst is nonbloody
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 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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

35. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
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
Urethral stricture; pelvic of urethral trauma
Tendons more likely

36. most frequent complication of TURP
Brardycardia - HTN - resp depression
Retrograde ejaculation
Progressive fibrosis of palmar fascia. etiololgy not known;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

37. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
ACL injury
CRPS
Elderly and critically ill patients
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. How to differentiate ACL and meniscus injury
Seminomas
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Nonunion and avascular necrosis; fx can block blood supply;

39. When patient can go back to sports after clavicle fx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
4-6 weeks for noncontact sports and longer time for contact sports
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If any compressive symptoms eg. dysphagia

40. 3 mo with groin bulge; bulge appears when child cries
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

41. inhalation of hot air - steam - smoke in burn victim
15-40%; self limiting;doesn't require tx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Meniscus injury; medial most common; pain/swelling; popping sensation
Supraglottic edema; low threshold for intubation

42. types of hip fracture
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

43. clavicle fx
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Displaced ORIF ; nondisplaced sling immobilization
Elevated non seminomas
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

44. cat/dog bites
Amoxicillin-clavulanate
Meniscus injury; medial most common; pain/swelling; popping sensation
ACL injury
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

45. dumping syndrome after gastrectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Tendons more likely
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

46. transrectal prostate biopsy
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Headache - ataxia - bulbar dysfunction

47. 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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

48. first line of management of PVD
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
SAH due to post communicating artery aneurysm;

49. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Twisting force with the foot fixed on the ground seen in football and basketball games;

50. popping sensation; rapid onset of knee effusion. athelet
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Twisting force with the foot fixed on the ground seen in football and basketball games;
ACL injury