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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. diarrhoea 4-5 days after cholecystectomy
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

2. What types of breast implants are available
Saline and silicone
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;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

3. aspiration of breast cyst is bloody
Mammogram
Urethral stricture; pelvic of urethral trauma
Malignancy until proven otherwise
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

4. What is terrible triad
Dumping syndrome; small and frequent meals; no simple sugar
CRPS
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

5. indication of ursodeoxycholic acid
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury
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

6. managment of animal bite in hands
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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;
Urethral stricture; pelvic of urethral trauma

7. management of gunshot wound
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Patellar tendon tear; difficulty in extension
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

8. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elevated non seminomas

9. when patient with severe lung disease have C02 retention
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Unilateral vocal cord paralysis

10. aspiration of breast cyst is nonbloody
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
S2-S4
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis

11. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

12. pregnant patient with asymptomatic gall stones
If any compressive symptoms eg. dysphagia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
ACL injury

13. How to differentiate ACL and meniscus injury
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
Pure motor stroke; limited neurological dysfunction
24-48 hours of supportive therapy followed by cholecystectomy
Twisting force with the foot fixed on the ground seen in football and basketball games;

14. stress fx
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
When urethral catherization is unsuccessful

15. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
24-48 hours of supportive therapy followed by cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pure motor stroke; limited neurological dysfunction

16. conservative Tx of varicose veins
Abd pain and tenderness; bloody diarrhoea or hematochezia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Compression stocking - weight reduction - leg elevation

17. 3 mo with groin bulge; bulge appears when child cries
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

18. What is the contraindication of hyperventilation in inc ICP
Compression stocking - weight reduction - leg elevation
Urethral stricture; pelvic of urethral trauma
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Strok and traumatic brain injury

19. what size of ureteral stone for non op mx
Seminomas
Less than 5mm
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 patient ambulatory - surgery and pain control; if not nonop mx

20. types of hip fracture
Meniscus injury; medial most common; pain/swelling; popping sensation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

21. midline neck swelling moves with protrusion of tongue
Displaced ORIF ; nondisplaced sling immobilization
CRPS
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

22. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Brardycardia - HTN - resp depression
10-12 months
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

23. 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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ispilateral hypoglossal nerve injury
Saline and silicone

24. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Even after ochiopexy risk of ochiopexy higher then general population

25. 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
Even after ochiopexy risk of ochiopexy higher then general population
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

26. first line of management of PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

27. menisci injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Tendons more likely
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;

28. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Nonunion and avascular necrosis; fx can block blood supply;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Check ET tube placement if correct needle decompresion

29. Dupuytren contracture
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

30. painless testicular mass in young male
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Nonunion and avascular necrosis; fx can block blood supply;
Malignancy until proven otherwise

31. sudden onset of postoperative hyperglycemia when patient on TPN
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Supraglottic edema; low threshold for intubation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pure motor stroke; limited neurological dysfunction

32. What time frame required for bone remodeling
10-12 months
Patellar tendon tear; difficulty in extension
15-40%; self limiting;doesn't require tx
Mammogram

33. How mcmurray manuver perform
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
Strok and traumatic brain injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

34. ct scan; cystic lesion in head of pancreas; next step
Carpal tunnel syndrom
Klinefelter syndrome; 50 fold increase;
Abd pain and tenderness; bloody diarrhoea or hematochezia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

35. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
ACL injury
CRPS

36. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
Klinefelter syndrome; 50 fold increase;
15-40%; self limiting;doesn't require tx

37. tx distal rectal ca
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Cystic scrotal fluid collection between parietal and visceral layers of testis

38. recurrent laryngeal nerve injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Unilateral vocal cord paralysis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

39. complications of TPN
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
CRPS
Study showed no adverse effect; but they are contraindicated for PVD
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

40. acalculus cholecystitis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Elderly and critically ill patients
Twisting force with the foot fixed on the ground seen in football and basketball games;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

41. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Mammogram

42. several knee pain after being tackled in football game
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Twisting force with the foot fixed on the ground seen in football and basketball games;

43. perioral numbness after parathyroidectomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

44. dorsiflexion and planter flexion
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Fx displace >1mm - nonunion during followup - osteonecrosis
L5 to S2

45. differential of ultrasound finding of breast mass
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Study showed no adverse effect; but they are contraindicated for PVD
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

46. severe pain in leg after MVC
Study showed no adverse effect; but they are contraindicated for PVD
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
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

47. Indication for bariatric surgery in obese patients
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
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;
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

48. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Meniscus injury; medial most common; pain/swelling; popping sensation

49. What is the complications of undescended testis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Amoxicillin-clavulanate
Even after ochiopexy risk of ochiopexy higher then general population
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

50. Why ruq calcificaion is concerning
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Unilateral vocal cord paralysis