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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 is hungry bone syndrome?
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

3. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Dm neuropathy; stocking glove pattern

4. Tx of proximal non metastatic rectal ca
Displaced ORIF ; nondisplaced sling immobilization
Low anterior resection and radio; add chemo if node positive
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

5. indication of ursodeoxycholic acid
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Low anterior resection and radio; add chemo if node positive
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

6. How mcmurray manuver perform
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Elevated non seminomas

7. acalculus cholecystitis
Elderly and critically ill patients
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

8. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
When urethral catherization is unsuccessful
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

9. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Patellar tendon tear; difficulty in extension
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Study showed no adverse effect; but they are contraindicated for PVD
Compression stocking - weight reduction - leg elevation

10. xray finding of stress fx after 3-4w
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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;

11. ipsilateral deviation of tongue upon protrusion
Progressive fibrosis of palmar fascia. etiololgy not known;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
50%; tunneling between rectum or kin
Ispilateral hypoglossal nerve injury

12. when patient with severe lung disease have C02 retention
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Displaced ORIF ; nondisplaced sling immobilization
Retrograde ejaculation

13. management of stone 8-10mm
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If patient ambulatory - surgery and pain control; if not nonop mx

14. pregnant patient with asymptomatic gall stones
Saline and silicone
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
4-6 weeks for noncontact sports and longer time for contact sports
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

15. first line of management of PVD
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

16. midline neck swelling moves with protrusion of tongue
50%; tunneling between rectum or kin
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

17. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
24-48 hours of supportive therapy followed by cholecystectomy

18. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

19. common complication of inadequate mx of scaphoid fx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Nonunion and avascular necrosis; fx can block blood supply;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

20. What types of breast implants are available
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Saline and silicone
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

21. beta hcg and AFP
Elevated non seminomas
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

22. What time frame required for bone remodeling
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
10-12 months
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

23. most common complication of acute cholecystitis
Fx displace >1mm - nonunion during followup - osteonecrosis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

24. How to perform lachman test
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

25. dumping syndrome after gastrectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevated non seminomas

26. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Malignancy until proven otherwise

27. transrectal prostate biopsy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Dumping syndrome; small and frequent meals; no simple sugar
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

28. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dumping syndrome; small and frequent meals; no simple sugar
Less than 5mm
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

29. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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;
Meniscus injury; medial most common; pain/swelling; popping sensation
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

30. What is the complications of undescended testis
Dm neuropathy; stocking glove pattern
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Even after ochiopexy risk of ochiopexy higher then general population
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

31. aspiration of breast cyst is bloody
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
Mammogram
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

32. popping sensation; rapid onset of knee effusion. athelet
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Patellar tendon tear; difficulty in extension
ACL injury

33. Can we use beta blocker for pvd?
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
Study showed no adverse effect; but they are contraindicated for PVD
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

34. beta HCG
Headache - ataxia - bulbar dysfunction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
15-40%; self limiting;doesn't require tx
Seminomas

35. Why initial xrays are negative in scaphoid fx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Compression stocking - weight reduction - leg elevation
10-12 months
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

36. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abd pain and tenderness; bloody diarrhoea or hematochezia
Unilateral vocal cord paralysis

37. prostate enlarged - nontender - no nodularity - elevated PSA
Mammogram
Malignancy until proven otherwise
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
10-12 months

38. diarrhoea after gastric bypass
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;
Dumping syndrome; small and frequent meals; no simple sugar
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Abd pain and tenderness; bloody diarrhoea or hematochezia

39. When do we see complications due to hypophosphatemia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
SAH due to post communicating artery aneurysm;
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

40. scrotal trauma
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Next best step surgery; not ultrasound
Supraglottic edema; low threshold for intubation
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

41. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Even after ochiopexy risk of ochiopexy higher then general population

42. What is prehn sign?
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Mammogram
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

43. When to stop raloxifene before surgery
Ispilateral hypoglossal nerve injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
When urethral catherization is unsuccessful
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Amoxicillin-clavulanate

45. inhalation of hot air - steam - smoke in burn victim
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar

46. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

47. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
50%; tunneling between rectum or kin
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. What is hydrocele?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Check ET tube placement if correct needle decompresion

49. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
If any compressive symptoms eg. dysphagia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
L5 to S2

50. acute colonic ischemia
Meniscus injury; medial most common; pain/swelling; popping sensation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Carpal tunnel syndrom
Scrotal ultrasound; cystic and fluid filled collections are noncancerous