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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. severe pain in leg after MVC
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

2. surgery for acute cholecystities
When urethral catherization is unsuccessful
24-48 hours of supportive therapy followed by cholecystectomy
L5 to S2
If any compressive symptoms eg. dysphagia

3. DD of acute scrotal pain
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
24-48 hours of supportive therapy followed by cholecystectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

4. What is hydrocele?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

5. midline neck swelling moves with protrusion of tongue
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

6. management of nondisplaced scaphoid fx
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;
Displaced ORIF ; nondisplaced sling immobilization
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

7. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
When urethral catherization is unsuccessful
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;
Study showed no adverse effect; but they are contraindicated for PVD

8. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

9. mx of stress fx
24-48 hours of supportive therapy followed by cholecystectomy
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

10. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Tendons more likely
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dm neuropathy; stocking glove pattern
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

11. SOB - confusion - petechial rash after trauma - fracture
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Study showed no adverse effect; but they are contraindicated for PVD

12. When goiter needs surgery
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
Klinefelter syndrome; 50 fold increase;
If any compressive symptoms eg. dysphagia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

13. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

14. Can we use beta blocker for pvd?
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
Seminomas
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Study showed no adverse effect; but they are contraindicated for PVD

15. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

16. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

17. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
24-48 hours of supportive therapy followed by cholecystectomy

18. dumping syndrome after gastrectomy
S2-S4
Elderly and critically ill patients
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

19. How to perform lachman test
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

20. suprapubic catheterization
Ispilateral hypoglossal nerve injury
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;
Pure motor stroke; limited neurological dysfunction
When urethral catherization is unsuccessful

21. 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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

22. scrotal trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;
Next best step surgery; not ultrasound
Check ET tube placement if correct needle decompresion
Less than 5mm

23. When to stop raloxifene before surgery
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
Elderly and critically ill patients
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

24. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

25. Incidence of AF in CABG patient

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26. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury
Low anterior resection and radio; add chemo if node positive
Fx displace >1mm - nonunion during followup - osteonecrosis

27. clavicle fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Displaced ORIF ; nondisplaced sling immobilization
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

28. contraindication of urethral catheterization
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Urethral stricture; pelvic of urethral trauma
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

29. 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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Ispilateral hypoglossal nerve injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

30. Patient underwent CABG; postoperatively drowsy. most likely cause?
Elderly and critically ill patients
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
Brardycardia - HTN - resp depression
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

31. differential of ultrasound finding of breast mass
Progressive fibrosis of palmar fascia. etiololgy not known;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Saline and silicone

32. What types of breast implants are available
Retrograde ejaculation
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
Saline and silicone
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

33. xray finding of stress fx after 3-4w
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
Headache - ataxia - bulbar dysfunction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Patellar tendon tear; difficulty in extension

34. perioral numbness after parathyroidectomy
Urethral stricture; pelvic of urethral trauma
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Check ET tube placement if correct needle decompresion
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

35. types of hip fracture
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
ACL injury
Unilateral vocal cord paralysis

36. acute colonic ischemia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Abd pain and tenderness; bloody diarrhoea or hematochezia
SAH due to post communicating artery aneurysm;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

37. How to confirm dx of compartment syndrom
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2

38. aspiration of breast cyst is bloody
Cystic scrotal fluid collection between parietal and visceral layers of testis
Study showed no adverse effect; but they are contraindicated for PVD
Mammogram
Strok and traumatic brain injury

39. How varicocele causes testicular atrophy
Displaced ORIF ; nondisplaced sling immobilization
Elevated non seminomas
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Even after ochiopexy risk of ochiopexy higher then general population

40. dorsiflexion and planter flexion
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
L5 to S2
Seminomas
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

41. ipsilateral deviation of tongue upon protrusion
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
If patient ambulatory - surgery and pain control; if not nonop mx
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
Ispilateral hypoglossal nerve injury

42. pregnant patient with asymptomatic gall stones
Even after ochiopexy risk of ochiopexy higher then general population
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
Carpal tunnel syndrom

43. How to evaluate painless testicular swelling suspicious for cancer
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Displaced ORIF ; nondisplaced sling immobilization
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

44. transrectal prostate biopsy
Less than 5mm
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
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

45. How mcmurray manuver perform
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

46. What is most common lung injury after blunt chest trauma?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
10-12 months

47. What is cushing's triad
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
When urethral catherization is unsuccessful
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Brardycardia - HTN - resp depression

48. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

49. characteristics of ureteral stone?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Patellar tendon tear; difficulty in extension
Nonunion and avascular necrosis; fx can block blood supply;

50. most frequent complication of TURP
Abd pain and tenderness; bloody diarrhoea or hematochezia
Retrograde ejaculation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Epi and chest compressio for prolong period of time; atropine is given after epi;