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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. Patient underwent CABG; postoperatively drowsy. most likely cause?
Study showed no adverse effect; but they are contraindicated for PVD
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
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

2. Can we use beta blocker for pvd?
Compression stocking - weight reduction - leg elevation
Low anterior resection and radio; add chemo if node positive
Study showed no adverse effect; but they are contraindicated for PVD
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

3. lacunar stroke
Study showed no adverse effect; but they are contraindicated for PVD
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pure motor stroke; limited neurological dysfunction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

4. What is cushing's triad
Brardycardia - HTN - resp depression
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

5. Dupuytren contracture
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2
Elderly and critically ill patients
Progressive fibrosis of palmar fascia. etiololgy not known;

6. aspiration of breast cyst is nonbloody
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Less than 5mm

7. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
L5 to S2
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

8. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Compression stocking - weight reduction - leg elevation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Strok and traumatic brain injury

9. Incidence of AF in CABG patient

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10. How mcmurray manuver perform
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Compression stocking - weight reduction - leg elevation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

11. suprapubic catheterization
Retrograde ejaculation
When urethral catherization is unsuccessful
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ispilateral hypoglossal nerve injury

12. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Subphrenic abscess or other abdominal abscesses; order US or CT
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
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

13. mangement of localized lymphadenopathy
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Urethral stricture; pelvic of urethral trauma
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

14. How to dx ACL tear?
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
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

15. ipsilateral deviation of tongue upon protrusion
50%; tunneling between rectum or kin
SAH due to post communicating artery aneurysm;
Ispilateral hypoglossal nerve injury
ACL injury

16. management of stone 8-10mm
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Seminomas
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

17. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

18. complications of TPN
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

19. anal sphincter tone
S2-S4
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
10-12 months

20. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Tendons more likely
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
Amoxicillin-clavulanate

21. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

22. diarrhoea 4-5 days after cholecystectomy
Patellar tendon tear; difficulty in extension
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Malignancy until proven otherwise

23. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Tendons more likely
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

24. What percent of anal abscess deveolop fisutula
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Malignancy until proven otherwise
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
50%; tunneling between rectum or kin

25. How varicocele causes testicular atrophy
Urethral stricture; pelvic of urethral trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Displaced ORIF ; nondisplaced sling immobilization

26. What types of breast implants are available
Saline and silicone
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;

27. Why right varicocele is more concerning?

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28. varicocele
Check ET tube placement if correct needle decompresion
Meniscus injury; medial most common; pain/swelling; popping sensation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

29. conservative Tx of varicose veins
Patellar tendon tear; difficulty in extension
Compression stocking - weight reduction - leg elevation
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
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

30. dorsiflexion and planter flexion
Less than 5mm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
L5 to S2
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

31. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
4-6 weeks for noncontact sports and longer time for contact sports
Klinefelter syndrome; 50 fold increase;

32. cremasteric reflex test?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

33. What is the contraindication of hyperventilation in inc ICP
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Strok and traumatic brain injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro

34. sudden onset of postoperative hyperglycemia when patient on TPN
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

35. management of gunshot wound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Amoxicillin-clavulanate
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

36. when scaphoid fx patient needs to be referred to orthopedic
Supraglottic edema; low threshold for intubation
Fx displace >1mm - nonunion during followup - osteonecrosis
Compression stocking - weight reduction - leg elevation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

37. Tx of pulmonary contusion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Saline and silicone
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

38. DD of acute scrotal pain
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

39. Most common of sudden death due to steering wheel injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

40. lacerated wound in palmer surface of hand. what structure is injured?
Supraglottic edema; low threshold for intubation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Tendons more likely
Malignancy until proven otherwise

41. Why ruq calcificaion is concerning
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

42. What is prehn sign?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If patient ambulatory - surgery and pain control; if not nonop mx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

43. stress fx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Subphrenic abscess or other abdominal abscesses; order US or CT
Dumping syndrome; small and frequent meals; no simple sugar

44. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Compression stocking - weight reduction - leg elevation
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;
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

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

46. varicose veins with ulcer - bleeding and thrombophlebitits
CRPS
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar
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

47. first step for evaluation of testicular swelling
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

48. cat/dog bites
Even after ochiopexy risk of ochiopexy higher then general population
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Amoxicillin-clavulanate

49. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
24-48 hours of supportive therapy followed by cholecystectomy
Progressive fibrosis of palmar fascia. etiololgy not known;
Twisting force with the foot fixed on the ground seen in football and basketball games;

50. How to manage a patient with asystole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol