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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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

2. management of stone 8-10mm
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Amoxicillin-clavulanate

3. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Unilateral vocal cord paralysis
Amoxicillin-clavulanate
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

4. lacerated wound in palmer surface of hand. what structure is injured?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Tendons more likely
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

5. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Strok and traumatic brain injury

6. When patient can go back to sports after clavicle fx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If patient ambulatory - surgery and pain control; if not nonop mx
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;
4-6 weeks for noncontact sports and longer time for contact sports

7. How to confirm dx of compartment syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Amoxicillin-clavulanate
Retrograde ejaculation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

8. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

9. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Next best step surgery; not ultrasound
Subphrenic abscess or other abdominal abscesses; order US or CT
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

10. How to confirm achiles tendon rupture
If patient ambulatory - surgery and pain control; if not nonop mx
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
Displaced ORIF ; nondisplaced sling immobilization
Epi and chest compressio for prolong period of time; atropine is given after epi;

11. Complications of breast impant
Urethral stricture; pelvic of urethral trauma
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm
CRPS

12. What is the strongest risk factor for male breast cancer
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
15-40%; self limiting;doesn't require tx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Klinefelter syndrome; 50 fold increase;

13. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Unilateral vocal cord paralysis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If any compressive symptoms eg. dysphagia

14. scrotal trauma
Subphrenic abscess or other abdominal abscesses; order US or CT
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Next best step surgery; not ultrasound
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

15. midline neck swelling moves with protrusion of tongue
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

16. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Amoxicillin-clavulanate
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

17. acalculus cholecystitis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

18. lacunar stroke
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
ACL injury
Pure motor stroke; limited neurological dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia

19. indication of ursodeoxycholic acid
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
SAH due to post communicating artery aneurysm;
24-48 hours of supportive therapy followed by cholecystectomy
S2-S4

20. complications of TPN
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

21. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Klinefelter syndrome; 50 fold increase;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

22. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Strok and traumatic brain injury
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

23. acute colonic ischemia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

24. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

25. What is hungry bone syndrome?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Less than 5mm
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. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dm neuropathy; stocking glove pattern
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sphincter sparing surgery (local resection) - abdomnio perineal resection

27. 3 mo with groin bulge; bulge appears when child cries
Carpal tunnel syndrom
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

28. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

29. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

30. Most common of sudden death due to steering wheel injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

31. inhalation of hot air - steam - smoke in burn victim
Patellar tendon tear; difficulty in extension
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
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

32. When do we see complications due to hypophosphatemia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

33. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pure motor stroke; limited neurological dysfunction

34. 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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

35. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Even after ochiopexy risk of ochiopexy higher then general population

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Subphrenic abscess or other abdominal abscesses; order US or CT
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

37. What types of breast implants are available
MAT; medial meniscus injury; ACL and Tibial colateral ligament
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Saline and silicone
Ispilateral hypoglossal nerve injury

38. ct scan; cystic lesion in head of pancreas; next step
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Retrograde ejaculation
Mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

39. 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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

40. varicose veins with ulcer - bleeding and thrombophlebitits
Malignancy until proven otherwise
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. common complication of inadequate mx of scaphoid fx
Carpal tunnel syndrom
Pure motor stroke; limited neurological dysfunction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Nonunion and avascular necrosis; fx can block blood supply;

42. management of nondisplaced scaphoid fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Patellar tendon tear; difficulty in extension
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Subphrenic abscess or other abdominal abscesses; order US or CT

43. What is the complications of undescended 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
Even after ochiopexy risk of ochiopexy higher then general population
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

44. painless testicular mass in young male
Klinefelter syndrome; 50 fold increase;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Malignancy until proven otherwise
S2-S4

45. management of gunshot wound
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
Unilateral vocal cord paralysis
ACL injury
Mammogram

46. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Dm neuropathy; stocking glove pattern

47. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Pure motor stroke; limited neurological dysfunction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Less than 5mm
Meniscus injury; medial most common; pain/swelling; popping sensation

48. mx of stress fx
Progressive fibrosis of palmar fascia. etiololgy not known;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Cystic scrotal fluid collection between parietal and visceral layers of testis

49. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Progressive fibrosis of palmar fascia. etiololgy not known;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

50. Incidence of AF in CABG patient

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