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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. How to manage obesity
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

2. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity

3. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Less than 5mm
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

4. mangement of localized lymphadenopathy
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
L5 to S2
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

5. stress fx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If patient ambulatory - surgery and pain control; if not nonop mx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

6. xray finding of stress fx after 3-4w
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

7. perioral numbness after parathyroidectomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
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

8. cremasteric reflex test?
Epi and chest compressio for prolong period of time; atropine is given after epi;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

9. How varicocele causes testicular atrophy
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
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
Patellar tendon tear; difficulty in extension
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

10. What types of breast implants are available
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Twisting force with the foot fixed on the ground seen in football and basketball games;
Saline and silicone
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

11. How to differentiate communicative and non-communicative hydrocele
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
15-40%; self limiting;doesn't require tx

12. lacunar stroke
10-12 months
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Pure motor stroke; limited neurological dysfunction

13. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

14. how ABI help dx of PVD
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

15. differential of ultrasound finding of breast mass
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Mammogram
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

16. When goiter needs surgery
If any compressive symptoms eg. dysphagia
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;
Next best step surgery; not ultrasound
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

17. How to manage a patient with asystole
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Epi and chest compressio for prolong period of time; atropine is given after epi;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

18. menisci injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Twisting force with the foot fixed on the ground seen in football and basketball games;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Supraglottic edema; low threshold for intubation

19. mx of stress fx
If patient ambulatory - surgery and pain control; if not nonop mx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Next best step surgery; not ultrasound
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

20. complication displaced or communited distal radial fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Compression stocking - weight reduction - leg elevation
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Carpal tunnel syndrom

21. severe pain in leg after MVC
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dumping syndrome; small and frequent meals; no simple sugar

22. midline neck swelling moves with protrusion of tongue
When urethral catherization is unsuccessful
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
SAH due to post communicating artery aneurysm;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

23. sudden onset of postoperative hyperglycemia when patient on TPN
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2
10-12 months
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

24. What percent of anal abscess deveolop fisutula
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cystic scrotal fluid collection between parietal and visceral layers of testis
50%; tunneling between rectum or kin
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

25. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
L5 to S2
SAH due to post communicating artery aneurysm;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation

26. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dm neuropathy; stocking glove pattern

27. Why initial xrays are negative in scaphoid fx
Malignancy until proven otherwise
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

28. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Malignancy until proven otherwise
If any compressive symptoms eg. dysphagia
Brardycardia - HTN - resp depression

29. Patient underwent CABG; postoperatively drowsy. most likely cause?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
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

30. recurrent laryngeal nerve injury
24-48 hours of supportive therapy followed by cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Unilateral vocal cord paralysis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

31. Dupuytren contracture
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Progressive fibrosis of palmar fascia. etiololgy not known;

32. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Check ET tube placement if correct needle decompresion
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
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

33. painless testicular mass in young male
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Malignancy until proven otherwise
Tendons more likely
Meniscus injury; medial most common; pain/swelling; popping sensation

34. management of stone 8-10mm
Dumping syndrome; small and frequent meals; no simple sugar
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Next best step surgery; not ultrasound

35. 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
Malignancy until proven otherwise
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

36. What is terrible triad
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

37. dorsiflexion and planter flexion
L5 to S2
Patellar tendon tear; difficulty in extension
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
4-6 weeks for noncontact sports and longer time for contact sports

38. varicocele
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;
Nonunion and avascular necrosis; fx can block blood supply;
S2-S4

39. swelling and tenderness in anterior part of knee
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Patellar tendon tear; difficulty in extension
Even after ochiopexy risk of ochiopexy higher then general population
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

40. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Ispilateral hypoglossal nerve injury
Check ET tube placement if correct needle decompresion
Subphrenic abscess or other abdominal abscesses; order US or CT

41. management of nondisplaced scaphoid fx
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

42. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

43. most common fx when falling on outsretched hand
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

44. managment of animal bite in hands
CRPS
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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;

45. Tx of proximal non metastatic rectal ca
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Fx displace >1mm - nonunion during followup - osteonecrosis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Low anterior resection and radio; add chemo if node positive

46. What is hydrocele?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cystic scrotal fluid collection between parietal and visceral layers of testis
Strok and traumatic brain injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity

47. clavicle fx
If patient ambulatory - surgery and pain control; if not nonop mx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

48. indication of ursodeoxycholic acid
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

49. What is most common lung injury after blunt chest trauma?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
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
Check ET tube placement if correct needle decompresion

50. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Low anterior resection and radio; add chemo if node positive
L5 to S2