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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. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Check ET tube placement if correct needle decompresion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Urethral stricture; pelvic of urethral trauma

2. transrectal prostate biopsy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
15-40%; self limiting;doesn't require tx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

3. 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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Supraglottic edema; low threshold for intubation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

4. complication displaced or communited distal radial fx
15-40%; self limiting;doesn't require tx
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;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Carpal tunnel syndrom

5. most common complication of acute cholecystitis
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;
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

6. surgery for acute cholecystities
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy

7. Why ruq calcificaion is concerning
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
24-48 hours of supportive therapy followed by cholecystectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

8. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
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
Retrograde ejaculation
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

9. 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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
4-6 weeks for noncontact sports and longer time for contact sports
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

10. conservative Tx of varicose veins
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation
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

11. What is hydrocele?
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
Retrograde ejaculation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cystic scrotal fluid collection between parietal and visceral layers of testis

12. What is terrible triad
Sphincter sparing surgery (local resection) - abdomnio perineal resection
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mammogram
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

13. scrotal trauma
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
If patient ambulatory - surgery and pain control; if not nonop mx
Next best step surgery; not ultrasound
Cystic scrotal fluid collection between parietal and visceral layers of testis

14. Tx of pulmonary contusion
50%; tunneling between rectum or kin
ACL injury
Compression stocking - weight reduction - leg elevation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

15. beta HCG
Seminomas
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
SAH due to post communicating artery aneurysm;
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

16. tx distal rectal ca
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Ispilateral hypoglossal nerve injury
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

17. What types of breast implants are available
Saline and silicone
Fx displace >1mm - nonunion during followup - osteonecrosis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Meniscus injury; medial most common; pain/swelling; popping sensation

18. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Brardycardia - HTN - resp depression
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

19. What time frame required for bone remodeling
10-12 months
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
MAT; medial meniscus injury; ACL and Tibial colateral ligament

20. when scaphoid fx patient needs to be referred to orthopedic
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fx displace >1mm - nonunion during followup - osteonecrosis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Unilateral vocal cord paralysis

21. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Displaced ORIF ; nondisplaced sling immobilization
SAH due to post communicating artery aneurysm;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

22. complications of TPN
15-40%; self limiting;doesn't require tx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
CRPS
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

23. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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;

24. Why right varicocele is more concerning?

25. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

26. common complication of inadequate mx of scaphoid fx
Mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Nonunion and avascular necrosis; fx can block blood supply;

27. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

28. most frequent complication of TURP
4-6 weeks for noncontact sports and longer time for contact sports
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Retrograde ejaculation
Twisting force with the foot fixed on the ground seen in football and basketball games;

29. What is the strongest risk factor for male breast cancer
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Klinefelter syndrome; 50 fold increase;

30. Can we use beta blocker for pvd?
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Study showed no adverse effect; but they are contraindicated for PVD

31. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Displaced ORIF ; nondisplaced sling immobilization
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Supraglottic edema; low threshold for intubation

32. lacerated wound in palmer surface of hand. what structure is injured?
Carpal tunnel syndrom
4-6 weeks for noncontact sports and longer time for contact sports
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely

33. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Study showed no adverse effect; but they are contraindicated for PVD
Low anterior resection and radio; add chemo if node positive
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

34. Incidence of AF in CABG patient

35. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
CRPS

36. anal sphincter tone
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
S2-S4
Dm neuropathy; stocking glove pattern
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Supraglottic edema; low threshold for intubation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

38. beta hcg and AFP
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevated non seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;

39. aspiration of breast cyst is bloody
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

40. 3 mo with groin bulge; bulge appears when child cries
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

41. cat/dog bites
Amoxicillin-clavulanate
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Subphrenic abscess or other abdominal abscesses; order US or CT
10-12 months

42. first line of management of PVD
S2-S4
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Even after ochiopexy risk of ochiopexy higher then general population

44. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
When urethral catherization is unsuccessful
Meniscus injury; medial most common; pain/swelling; popping sensation
50%; tunneling between rectum or kin

45. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

46. swelling and tenderness in anterior part of knee
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Patellar tendon tear; difficulty in extension

47. How to manage obesity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
ACL injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

48. indication of ursodeoxycholic acid
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pure motor stroke; limited neurological dysfunction

49. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
L5 to S2
Next best step surgery; not ultrasound

50. mangement of localized lymphadenopathy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If any compressive symptoms eg. dysphagia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx