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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. What are the common injuries from lightning?
Strok and traumatic brain injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Fx displace >1mm - nonunion during followup - osteonecrosis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

2. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Subphrenic abscess or other abdominal abscesses; order US or CT

3. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Elderly and critically ill patients

4. Why varicocele more common in the left side
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

5. How to dx ACL tear?
S2-S4
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

6. recurrent laryngeal nerve injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
24-48 hours of supportive therapy followed by cholecystectomy
Unilateral vocal cord paralysis
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

7. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dm neuropathy; stocking glove pattern
Patellar tendon tear; difficulty in extension
If patient ambulatory - surgery and pain control; if not nonop mx

8. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Subphrenic abscess or other abdominal abscesses; order US or CT
Check ET tube placement if correct needle decompresion

9. severe pain in leg after MVC
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
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
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
Supraglottic edema; low threshold for intubation

10. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Dumping syndrome; small and frequent meals; no simple sugar
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

11. ipsilateral deviation of tongue upon protrusion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Brardycardia - HTN - resp depression
Ispilateral hypoglossal nerve injury
Supraglottic edema; low threshold for intubation

12. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
When urethral catherization is unsuccessful
10-12 months

13. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Even after ochiopexy risk of ochiopexy higher then general population

14. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Check ET tube placement if correct needle decompresion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

15. diarrhoea after gastric bypass
Retrograde ejaculation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Displaced ORIF ; nondisplaced sling immobilization
Dumping syndrome; small and frequent meals; no simple sugar

16. Indication for bariatric surgery in obese patients
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Abd pain and tenderness; bloody diarrhoea or hematochezia
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;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

17. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
CRPS
Ampicillin sublactum - pipercillin - ceftriaxone and metro

18. What time frame required for bone remodeling
Low anterior resection and radio; add chemo if node positive
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
10-12 months

19. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Mammogram
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

20. 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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If any compressive symptoms eg. dysphagia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

21. transrectal prostate biopsy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Progressive fibrosis of palmar fascia. etiololgy not known;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Mammogram

22. What is the strongest risk factor for male breast cancer
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Klinefelter syndrome; 50 fold increase;
Subphrenic abscess or other abdominal abscesses; order US or CT

23. menisci injury
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Twisting force with the foot fixed on the ground seen in football and basketball games;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

24. midline neck swelling moves with protrusion of tongue
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Urethral stricture; pelvic of urethral trauma
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

25. varicocele
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

26. acalculus cholecystitis
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

27. How to differentiate ACL and meniscus injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

28. anal sphincter tone
S2-S4
Twisting force with the foot fixed on the ground seen in football and basketball games;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

29. What is prehn sign?
Amoxicillin-clavulanate
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Unilateral vocal cord paralysis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

30. When patient can go back to sports after clavicle fx
Klinefelter syndrome; 50 fold increase;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4-6 weeks for noncontact sports and longer time for contact sports
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

31. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
4-6 weeks for noncontact sports and longer time for contact sports
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

32. Can we use beta blocker for pvd?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Subphrenic abscess or other abdominal abscesses; order US or CT
SAH due to post communicating artery aneurysm;
Study showed no adverse effect; but they are contraindicated for PVD

33. When to do surgery in undesceneded testis?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

34. perioral numbness after parathyroidectomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Amoxicillin-clavulanate

35. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
When urethral catherization is unsuccessful
Study showed no adverse effect; but they are contraindicated for PVD
CRPS

36. most frequent complication of TURP
Seminomas
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Retrograde ejaculation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

37. management of stone 8-10mm
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
Headache - ataxia - bulbar dysfunction
When urethral catherization is unsuccessful
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

38. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
When urethral catherization is unsuccessful
Subphrenic abscess or other abdominal abscesses; order US or CT
Malignancy until proven otherwise
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

39. Incidence of AF in CABG patient

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40. What types of breast implants are available
Saline and silicone
Displaced ORIF ; nondisplaced sling immobilization
Dm neuropathy; stocking glove pattern
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

41. painless testicular mass in young male
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Malignancy until proven otherwise

42. most common fx when falling on outsretched hand
Patellar tendon tear; difficulty in extension
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;
Elevated non seminomas

43. How to evaluate painless testicular swelling suspicious for cancer
Dumping syndrome; small and frequent meals; no simple sugar
Next best step surgery; not ultrasound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

44. Why right varicocele is more concerning?

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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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

46. sudden onset of postoperative hyperglycemia when patient on TPN
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
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

47. beta HCG
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Seminomas
Klinefelter syndrome; 50 fold increase;
S2-S4

48. clavicle fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Displaced ORIF ; nondisplaced sling immobilization

49. How to differentiate communicative and non-communicative hydrocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. dumping syndrome after gastrectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa