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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. sudden onset of postoperative hyperglycemia when patient on TPN
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

2. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

3. tx distal rectal ca
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4-6 weeks for noncontact sports and longer time for contact sports
Sphincter sparing surgery (local resection) - abdomnio perineal resection

4. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

5. What is prehn sign?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation

6. Why varicocele more common in the left side
Subphrenic abscess or other abdominal abscesses; order US or CT
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

7. anal sphincter tone
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;
Patellar tendon tear; difficulty in extension
S2-S4
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

8. managment of animal bite in hands
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Even after ochiopexy risk of ochiopexy higher then general population
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

9. indication of ursodeoxycholic acid
CRPS
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

10. varicocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
When urethral catherization is unsuccessful

11. lacunar stroke
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ACL injury
Pure motor stroke; limited neurological dysfunction
10-12 months

12. when scaphoid fx patient needs to be referred to orthopedic
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

13. ipsilateral deviation of tongue upon protrusion
Next best step surgery; not ultrasound
Ispilateral hypoglossal nerve injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Progressive fibrosis of palmar fascia. etiololgy not known;

14. What is hungry bone syndrome?
Mammogram
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
Supraglottic edema; low threshold for intubation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

15. What is most common lung injury after blunt chest trauma?
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
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
ACL 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;

16. How to dx ACL tear?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
10-12 months

17. What is terrible triad
4-6 weeks for noncontact sports and longer time for contact sports
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

18. scrotal trauma
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fx displace >1mm - nonunion during followup - osteonecrosis
Next best step surgery; not ultrasound
L5 to S2

19. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
15-40%; self limiting;doesn't require tx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Meniscus injury; medial most common; pain/swelling; popping sensation

20. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Nonunion and avascular necrosis; fx can block blood supply;
Check ET tube placement if correct needle decompresion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

21. Valgus and Varus tests
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Seminomas

22. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

23. several knee pain after being tackled in football game
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
Strok and traumatic brain injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

24. complication displaced or communited distal radial fx
Carpal tunnel syndrom
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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

25. most common fx when falling on outsretched hand
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Low anterior resection and radio; add chemo if node positive
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

26. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Meniscus injury; medial most common; pain/swelling; popping sensation
If any compressive symptoms eg. dysphagia
S2-S4
CRPS

27. beta HCG
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check ET tube placement if correct needle decompresion
Seminomas
Headache - ataxia - bulbar dysfunction

28. most frequent complication of TURP
When urethral catherization is unsuccessful
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation
4-6 weeks for noncontact sports and longer time for contact sports

29. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Abd pain and tenderness; bloody diarrhoea or hematochezia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Supraglottic edema; low threshold for intubation

30. How to differentiate communicative and non-communicative hydrocele
Amoxicillin-clavulanate
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

31. common complication of inadequate mx of scaphoid fx
Supraglottic edema; low threshold for intubation
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS
Nonunion and avascular necrosis; fx can block blood supply;

32. When do we see complications due to hypophosphatemia
Strok and traumatic brain injury
Headache - ataxia - bulbar dysfunction
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

33. first step for evaluation of testicular swelling
If any compressive symptoms eg. dysphagia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

34. 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
Study showed no adverse effect; but they are contraindicated for PVD
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

35. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Subphrenic abscess or other abdominal abscesses; order US or CT
ACL injury
S2-S4

36. Why right varicocele is more concerning?

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37. acute colonic ischemia
Check ET tube placement if correct needle decompresion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Abd pain and tenderness; bloody diarrhoea or hematochezia
24-48 hours of supportive therapy followed by cholecystectomy

38. Indication for bariatric surgery in obese patients
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;

39. dorsiflexion and planter flexion
SAH due to post communicating artery aneurysm;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Displaced ORIF ; nondisplaced sling immobilization
L5 to S2

40. What are the common injuries from lightning?
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dm neuropathy; stocking glove pattern

41. varicose veins with ulcer - bleeding and thrombophlebitits
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If any compressive symptoms eg. dysphagia
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

42. beta hcg and AFP
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Saline and silicone

43. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

44. menisci injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Twisting force with the foot fixed on the ground seen in football and basketball games;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cystic scrotal fluid collection between parietal and visceral layers of testis

45. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Low anterior resection and radio; add chemo if node positive
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
15-40%; self limiting;doesn't require tx
SAH due to post communicating artery aneurysm;

46. 3 mo with groin bulge; bulge appears when child cries
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check ET tube placement if correct needle decompresion

47. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Saline and silicone
If any compressive symptoms eg. dysphagia
Brardycardia - HTN - resp depression

48. severe pain in leg after MVC
Brardycardia - HTN - resp depression
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

49. mx of stress fx
Elderly and critically ill patients
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. suprapubic catheterization
When urethral catherization is unsuccessful
Compression stocking - weight reduction - leg elevation
Study showed no adverse effect; but they are contraindicated for PVD
Ispilateral hypoglossal nerve injury