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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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. popping sensation; rapid onset of knee effusion. athelet
If any compressive symptoms eg. dysphagia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
ACL injury

2. What time frame required for bone remodeling
Saline and silicone
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months

3. several knee pain after being tackled in football game
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Less than 5mm

4. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Less than 5mm
Nonunion and avascular necrosis; fx can block blood supply;

5. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

6. 3 mo with groin bulge; bulge appears when child cries
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
S2-S4
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

7. cat/dog bites
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
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
Amoxicillin-clavulanate
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

8. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

9. dumping syndrome after gastrectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

10. lacunar stroke
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
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Pure motor stroke; limited neurological dysfunction

11. contraindication of urethral catheterization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Urethral stricture; pelvic of urethral trauma
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive

12. How varicocele causes testicular atrophy
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
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
Meniscus injury; medial most common; pain/swelling; popping sensation

13. management of stone 8-10mm
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
4-6 weeks for noncontact sports and longer time for contact sports
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

14. types of hip fracture
15-40%; self limiting;doesn't require tx
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

15. dorsiflexion and planter flexion
Dm neuropathy; stocking glove pattern
Study showed no adverse effect; but they are contraindicated for PVD
Displaced ORIF ; nondisplaced sling immobilization
L5 to S2

16. antibiotics of acute cholecystitis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Patellar tendon tear; difficulty in extension
Ampicillin sublactum - pipercillin - ceftriaxone and metro

17. ct scan; cystic lesion in head of pancreas; next step
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
Amoxicillin-clavulanate
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

18. Can we use beta blocker for pvd?
Check ET tube placement if correct needle decompresion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
50%; tunneling between rectum or kin
Study showed no adverse effect; but they are contraindicated for PVD

19. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

20. painless testicular mass in young male
Malignancy until proven otherwise
Displaced ORIF ; nondisplaced sling immobilization
Amoxicillin-clavulanate
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

21. When patient can go back to sports after clavicle fx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
4-6 weeks for noncontact sports and longer time for contact sports
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

22. 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
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

23. inhalation of hot air - steam - smoke in burn victim
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Brardycardia - HTN - resp depression
Klinefelter syndrome; 50 fold increase;
Supraglottic edema; low threshold for intubation

24. characteristics of ureteral stone?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Tendons more likely
10-12 months
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. How mcmurray manuver perform
Strok and traumatic brain injury
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;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Nonunion and avascular necrosis; fx can block blood supply;

26. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Urethral stricture; pelvic of urethral trauma
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dm neuropathy; stocking glove pattern
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

27. when scaphoid fx patient needs to be referred to orthopedic
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
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Ampicillin sublactum - pipercillin - ceftriaxone and metro

28. pregnant patient with asymptomatic gall stones
Supraglottic edema; low threshold for intubation
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If patient ambulatory - surgery and pain control; if not nonop mx

29. most frequent complication of TURP
Retrograde ejaculation
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Amoxicillin-clavulanate

30. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Check ET tube placement if correct needle decompresion
Nonunion and avascular necrosis; fx can block blood supply;

31. How to perform lachman test
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

32. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Subphrenic abscess or other abdominal abscesses; order US or CT
Retrograde ejaculation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

33. Most common of sudden death due to steering wheel injury
15-40%; self limiting;doesn't require tx
Even after ochiopexy risk of ochiopexy higher then general population
Less than 5mm
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

34. varicose veins with ulcer - bleeding and thrombophlebitits
4-6 weeks for noncontact sports and longer time for contact sports
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Subphrenic abscess or other abdominal abscesses; order US or CT
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

35. management of hip fracture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

36. perioral numbness after parathyroidectomy
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Displaced ORIF ; nondisplaced sling immobilization
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

37. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If any compressive symptoms eg. dysphagia
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma

38. prostate enlarged - nontender - no nodularity - elevated PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. complications of TPN
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

40. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Low anterior resection and radio; add chemo if node positive
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
Brardycardia - HTN - resp depression

41. 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
Strok and traumatic brain injury
Dm neuropathy; stocking glove pattern
MAT; medial meniscus injury; ACL and Tibial colateral ligament

42. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Saline and silicone

43. cremasteric reflex
Supraglottic edema; low threshold for intubation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Progressive fibrosis of palmar fascia. etiololgy not known;
Amoxicillin-clavulanate

44. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
If patient ambulatory - surgery and pain control; if not nonop mx
Displaced ORIF ; nondisplaced sling immobilization
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

45. cremasteric reflex test?
Malignancy until proven otherwise
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months

46. How to dx ACL tear?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
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
24-48 hours of supportive therapy followed by cholecystectomy

47. aspiration of breast cyst is nonbloody
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Seminomas
Retrograde ejaculation

48. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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

49. Why initial xrays are negative in scaphoid fx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

50. differential of ultrasound finding of breast mass
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Check ET tube placement if correct needle decompresion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;