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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. midline neck swelling moves with protrusion of tongue
Nonunion and avascular necrosis; fx can block blood supply;
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
Study showed no adverse effect; but they are contraindicated for PVD

2. most frequent complication of TURP
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
SAH due to post communicating artery aneurysm;
Retrograde ejaculation
Study showed no adverse effect; but they are contraindicated for PVD

3. 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
CRPS
Less than 5mm
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

4. Indication for bariatric surgery in obese patients
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elderly and critically ill patients

5. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Retrograde ejaculation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

6. how hyperventilation lowers ICP
Less than 5mm
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Mammogram

7. severe pain in leg after MVC
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
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;
Cystic scrotal fluid collection between parietal and visceral layers of testis

8. What is the complications of undescended testis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cystic scrotal fluid collection between parietal and visceral layers of testis
Even after ochiopexy risk of ochiopexy higher then general population

9. varicose veins with ulcer - bleeding and thrombophlebitits
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;
Amoxicillin-clavulanate
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

10. How to manage a patient with asystole
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Epi and chest compressio for prolong period of time; atropine is given after epi;
24-48 hours of supportive therapy followed by cholecystectomy
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

11. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population

12. SAH due to posterior inferior cerebellar aneurysm
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;
Nonunion and avascular necrosis; fx can block blood supply;
Headache - ataxia - bulbar dysfunction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

13. Tx of proximal non metastatic rectal ca
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Low anterior resection and radio; add chemo if node positive

14. diarrhoea 4-5 days after cholecystectomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

15. what size of ureteral stone for non op mx
Klinefelter syndrome; 50 fold increase;
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
Amoxicillin-clavulanate
Less than 5mm

16. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
When urethral catherization is unsuccessful
Study showed no adverse effect; but they are contraindicated for PVD

17. sudden onset of postoperative hyperglycemia when patient on TPN
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mammogram

18. 3 mo with groin bulge; bulge appears when child cries
Headache - ataxia - bulbar dysfunction
Seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

19. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Carpal tunnel syndrom

20. Dupuytren contracture
Headache - ataxia - bulbar dysfunction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Progressive fibrosis of palmar fascia. etiololgy not known;
Nonunion and avascular necrosis; fx can block blood supply;

21. How to perform lachman test
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Patellar tendon tear; difficulty in extension
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

22. swelling and tenderness in anterior part of knee
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Patellar tendon tear; difficulty in extension
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
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

23. mx of stress fx
ACL injury
Displaced ORIF ; nondisplaced sling immobilization
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

24. perioral numbness after parathyroidectomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
When urethral catherization is unsuccessful
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

25. scrotal trauma
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Next best step surgery; not ultrasound
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

26. How mcmurray manuver perform
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
Urethral stricture; pelvic of urethral trauma
L5 to S2
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

27. management of stone 8-10mm
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

28. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Strok and traumatic brain injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

29. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
S2-S4
If patient ambulatory - surgery and pain control; if not nonop mx

30. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If any compressive symptoms eg. dysphagia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis

31. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Fx displace >1mm - nonunion during followup - osteonecrosis
CRPS

32. 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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Displaced ORIF ; nondisplaced sling immobilization
Low anterior resection and radio; add chemo if node positive

33. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Carpal tunnel syndrom
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

34. when patient with severe lung disease have C02 retention
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

35. prostate enlarged - nontender - no nodularity - elevated PSA
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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

36. complications of TPN
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. cat/dog bites
Strok and traumatic brain injury
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
Amoxicillin-clavulanate
Tendons more likely

38. DD of acute scrotal pain
Malignancy until proven otherwise
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elderly and critically ill patients
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

39. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
CRPS
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

40. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Urethral stricture; pelvic of urethral trauma

41. dumping syndrome after gastrectomy
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

42. ipsilateral deviation of tongue upon protrusion
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Ispilateral hypoglossal nerve injury

43. diarrhoea after gastric bypass
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dumping syndrome; small and frequent meals; no simple sugar
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

44. management of gunshot wound
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Retrograde ejaculation

45. popping sensation; rapid onset of knee effusion. athelet
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
ACL injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

46. mangement of localized lymphadenopathy
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Dm neuropathy; stocking glove pattern

47. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx

48. inhalation of hot air - steam - smoke in burn victim
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If any compressive symptoms eg. dysphagia
Pure motor stroke; limited neurological dysfunction
Supraglottic edema; low threshold for intubation

49. common complication of inadequate mx of scaphoid fx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Supraglottic edema; low threshold for intubation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Nonunion and avascular necrosis; fx can block blood supply;

50. 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
When urethral catherization is unsuccessful
Low anterior resection and radio; add chemo if node positive
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction