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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. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Retrograde ejaculation
Dumping syndrome; small and frequent meals; no simple sugar
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

2. Why initial xrays are negative in scaphoid fx
Study showed no adverse effect; but they are contraindicated for PVD
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

3. Indication for bariatric surgery in obese patients
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;
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
Strok and traumatic brain injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

4. SOB - confusion - petechial rash after trauma - fracture
Pure motor stroke; limited neurological dysfunction
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

5. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Retrograde ejaculation
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
Subphrenic abscess or other abdominal abscesses; order US or CT

6. Patient underwent CABG; postoperatively drowsy. most likely cause?
Klinefelter syndrome; 50 fold increase;
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
Seminomas
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

7. suprapubic catheterization
When urethral catherization is unsuccessful
Even after ochiopexy risk of ochiopexy higher then general population
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
15-40%; self limiting;doesn't require tx

8. What is the complications of undescended testis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Less than 5mm
Even after ochiopexy risk of ochiopexy higher then general population

9. prostate enlarged - nontender - no nodularity - elevated PSA
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dumping syndrome; small and frequent meals; no simple sugar
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

10. how ABI help dx of PVD
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Elderly and critically ill patients
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

11. midline neck swelling moves with protrusion of tongue
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
CRPS
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

12. What is most common lung injury after blunt chest trauma?
Even after ochiopexy risk of ochiopexy higher then general population
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
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
Carpal tunnel syndrom

13. first step for evaluation of testicular swelling
Progressive fibrosis of palmar fascia. etiololgy not known;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Pure motor stroke; limited neurological dysfunction

14. Can we use beta blocker for pvd?
Meniscus injury; medial most common; pain/swelling; popping sensation
Amoxicillin-clavulanate
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Study showed no adverse effect; but they are contraindicated for PVD

15. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
CRPS

16. complications of TPN
Cystic scrotal fluid collection between parietal and visceral layers of testis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abd pain and tenderness; bloody diarrhoea or hematochezia

17. acute colonic ischemia
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Abd pain and tenderness; bloody diarrhoea or hematochezia
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

18. when scaphoid fx patient needs to be referred to orthopedic
When urethral catherization is unsuccessful
Fx displace >1mm - nonunion during followup - osteonecrosis
Subphrenic abscess or other abdominal abscesses; order US or CT
S2-S4

19. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Meniscus injury; medial most common; pain/swelling; popping sensation
MAT; medial meniscus injury; ACL and Tibial colateral ligament

20. How to confirm dx of compartment syndrom
Subphrenic abscess or other abdominal abscesses; order US or CT
Twisting force with the foot fixed on the ground seen in football and basketball games;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

21. What is the strongest risk factor for male breast cancer
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Klinefelter syndrome; 50 fold increase;

22. antibiotics of acute cholecystitis
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

23. dumping syndrome after gastrectomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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 any compressive symptoms eg. dysphagia

24. 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
Compression stocking - weight reduction - leg elevation
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

25. scrotal trauma
Next best step surgery; not ultrasound
Less than 5mm
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 mesenteric ishemia; most SMA occlusion secondary to an embolism

26. Dupuytren contracture
S2-S4
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

27. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

28. When to do surgery in undesceneded testis?
15-40%; self limiting;doesn't require tx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Study showed no adverse effect; but they are contraindicated for PVD
Fx displace >1mm - nonunion during followup - osteonecrosis

29. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
CRPS

30. common complication of inadequate mx of scaphoid fx
Displaced ORIF ; nondisplaced sling immobilization
Nonunion and avascular necrosis; fx can block blood supply;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
CRPS

31. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

32. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Headache - ataxia - bulbar dysfunction
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
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;

33. How to manage a patient with asystole
If patient ambulatory - surgery and pain control; if not nonop mx
Headache - ataxia - bulbar dysfunction
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;

34. ct scan; cystic lesion in head of pancreas; next step
Seminomas
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

35. diarrhoea 4-5 days after cholecystectomy
Saline and silicone
CRPS
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

36. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Cystic scrotal fluid collection between parietal and visceral layers of testis
ACL injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

37. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Strok and traumatic brain injury
Unilateral vocal cord paralysis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

38. lacerated wound in palmer surface of hand. what structure is injured?
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Tendons more likely

39. menisci injury
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Twisting force with the foot fixed on the ground seen in football and basketball games;

40. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. beta HCG
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
Low anterior resection and radio; add chemo if node positive
Seminomas
Compression stocking - weight reduction - leg elevation

42. inhalation of hot air - steam - smoke in burn victim
Patellar tendon tear; difficulty in extension
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Supraglottic edema; low threshold for intubation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

43. What percent of anal abscess deveolop fisutula
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If patient ambulatory - surgery and pain control; if not nonop mx
50%; tunneling between rectum or kin
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

44. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
SAH due to post communicating artery aneurysm;
Elevated non seminomas

45. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If any compressive symptoms eg. dysphagia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Urethral stricture; pelvic of urethral trauma

46. dorsiflexion and planter flexion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If patient ambulatory - surgery and pain control; if not nonop mx
Tendons more likely
L5 to S2

47. How to differentiate communicative and non-communicative hydrocele
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 full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

48. recurrent laryngeal nerve injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Unilateral vocal cord paralysis

49. what size of ureteral stone for non op mx
Compression stocking - weight reduction - leg elevation
Less than 5mm
Cystic scrotal fluid collection between parietal and visceral layers of testis
24-48 hours of supportive therapy followed by cholecystectomy

50. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Malignancy until proven otherwise
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
10-12 months
Subphrenic abscess or other abdominal abscesses; order US or CT