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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. when patient with severe lung disease have C02 retention
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
Elderly and critically ill patients
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

2. Patient underwent CABG; postoperatively drowsy. most likely cause?
When urethral catherization is unsuccessful
Supraglottic edema; low threshold for intubation
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

3. beta hcg and AFP
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Elevated non seminomas
Check ET tube placement if correct needle decompresion

4. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Retrograde ejaculation

5. diarrhoea after gastric bypass
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Dumping syndrome; small and frequent meals; no simple sugar
Elevated non seminomas

6. How to manage obesity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Strok and traumatic brain injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

7. cat/dog bites
10-12 months
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;
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

8. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Fx displace >1mm - nonunion during followup - osteonecrosis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Ampicillin sublactum - pipercillin - ceftriaxone and metro

9. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

10. 3 mo with groin bulge; bulge appears when child cries
15-40%; self limiting;doesn't require tx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful

11. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Ispilateral hypoglossal nerve injury
CRPS
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

12. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Meniscus injury; medial most common; pain/swelling; popping sensation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Check ET tube placement if correct needle decompresion
Dumping syndrome; small and frequent meals; no simple sugar

13. How to perform lachman test
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

14. management of nondisplaced scaphoid fx
Displaced ORIF ; nondisplaced sling immobilization
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Saline and silicone

15. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT

16. How to confirm achiles tendon rupture
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
Pure motor stroke; limited neurological dysfunction
Patellar tendon tear; difficulty in extension
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

17. clavicle fx
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;
Displaced ORIF ; nondisplaced sling immobilization
Klinefelter syndrome; 50 fold increase;
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;

18. Can we use beta blocker for pvd?
Low anterior resection and radio; add chemo if node positive
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Study showed no adverse effect; but they are contraindicated for PVD
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

19. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

20. menisci injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Check ET tube placement if correct needle decompresion
Dumping syndrome; small and frequent meals; no simple sugar
Twisting force with the foot fixed on the ground seen in football and basketball games;

21. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Displaced ORIF ; nondisplaced sling immobilization

22. antibiotics of acute cholecystitis
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

23. how ABI help dx of PVD
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
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. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Carpal tunnel syndrom
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

25. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Abd pain and tenderness; bloody diarrhoea or hematochezia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

26. xray finding of stress fx after 3-4w
Even after ochiopexy risk of ochiopexy higher then general population
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

27. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Subphrenic abscess or other abdominal abscesses; order US or CT
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

28. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

29. When to stop raloxifene before surgery
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
When urethral catherization is unsuccessful

30. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dm neuropathy; stocking glove pattern
Next best step surgery; not ultrasound
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

31. suprapubic catheterization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
When urethral catherization is unsuccessful
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
24-48 hours of supportive therapy followed by cholecystectomy

32. most common complication of acute cholecystitis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

33. What time frame required for bone remodeling
Brardycardia - HTN - resp depression
10-12 months
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
24-48 hours of supportive therapy followed by cholecystectomy

34. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Urethral stricture; pelvic of urethral trauma
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

35. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Malignancy until proven otherwise
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

36. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
S2-S4
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

37. What are the common injuries from lightning?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

38. When do we see complications due to hypophosphatemia
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
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

39. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

40. varicose veins with ulcer - bleeding and thrombophlebitits
Elevated non seminomas
Check ET tube placement if correct needle decompresion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

41. SOB - confusion - petechial rash after trauma - fracture
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Seminomas

42. 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
CRPS
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

43. How mcmurray manuver perform
24-48 hours of supportive therapy followed by cholecystectomy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

44. transrectal prostate biopsy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Klinefelter syndrome; 50 fold increase;
Carpal tunnel syndrom

45. What is hungry bone syndrome?
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

46. How to differentiate ACL and meniscus injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

47. inhalation of hot air - steam - smoke in burn victim
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Supraglottic edema; low threshold for intubation
Study showed no adverse effect; but they are contraindicated for PVD
Less than 5mm

48. common complication of inadequate mx of scaphoid fx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Nonunion and avascular necrosis; fx can block blood supply;
Dm neuropathy; stocking glove pattern

49. When to do surgery in undesceneded testis?
Low anterior resection and radio; add chemo if node positive
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

50. How to manage a patient with asystole
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
15-40%; self limiting;doesn't require tx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism