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USMLE Step3 Surgery
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Subjects
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health-sciences
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usmle-step-3
Instructions:
Answer 50 questions in 15 minutes.
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study here
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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. When do we see complications due to hypophosphatemia
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;
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Headache - ataxia - bulbar dysfunction
2. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Elevated non seminomas
Less than 5mm
SAH due to post communicating artery aneurysm;
3. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Klinefelter syndrome; 50 fold increase;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
4. How to manage a patient with asystole
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;
5. What types of breast implants are available
Saline and silicone
S2-S4
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
When urethral catherization is unsuccessful
6. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Progressive fibrosis of palmar fascia. etiololgy not known;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Tendons more likely
7. When patient can go back to sports after clavicle fx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4-6 weeks for noncontact sports and longer time for contact sports
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
8. Dupuytren contracture
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
9. painless testicular mass in young male
Malignancy until proven otherwise
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
10. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
11. Tx of pulmonary contusion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Progressive fibrosis of palmar fascia. etiololgy not known;
12. management of gunshot wound
Urethral stricture; pelvic of urethral trauma
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
10-12 months
13. ipsilateral deviation of tongue upon protrusion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Unilateral vocal cord paralysis
Urethral stricture; pelvic of urethral trauma
Ispilateral hypoglossal nerve injury
14. management of hip fracture
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Urethral stricture; pelvic of urethral trauma
If patient ambulatory - surgery and pain control; if not nonop mx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
15. aspiration of breast cyst is bloody
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
Mammogram
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;
15-40%; self limiting;doesn't require tx
16. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Supraglottic edema; low threshold for intubation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
15-40%; self limiting;doesn't require tx
17. How to perform lachman test
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Malignancy until proven otherwise
18. common complication of inadequate mx of scaphoid fx
L5 to S2
Nonunion and avascular necrosis; fx can block blood supply;
Even after ochiopexy risk of ochiopexy higher then general population
Klinefelter syndrome; 50 fold increase;
19. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevated non seminomas
Carpal tunnel syndrom
20. transrectal prostate biopsy
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
21. Patient underwent CABG; postoperatively drowsy. most likely cause?
15-40%; self limiting;doesn't require tx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture 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
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
22. acute colonic ischemia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Abd pain and tenderness; bloody diarrhoea or hematochezia
50%; tunneling between rectum or kin
Carpal tunnel syndrom
23. indication of ursodeoxycholic acid
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
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
Strok and traumatic brain injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
24. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If patient ambulatory - surgery and pain control; if not nonop mx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Compression stocking - weight reduction - leg elevation
25. ct scan; cystic lesion in head of pancreas; next step
Headache - ataxia - bulbar dysfunction
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Ispilateral hypoglossal nerve injury
26. mangement of localized lymphadenopathy
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
27. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
28. varicocele
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;
50%; tunneling between rectum or kin
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
29. managment of animal bite in hands
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
30. How to dx ACL tear?
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
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
31. beta hcg and AFP
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elevated non seminomas
Elderly and critically ill patients
Strok and traumatic brain injury
32. popping sensation; rapid onset of knee effusion. athelet
ACL 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;
10-12 months
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
33. menisci injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Twisting force with the foot fixed on the ground seen in football and basketball games;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
34. scrotal trauma
Nonunion and avascular necrosis; fx can block blood supply;
Next best step surgery; not ultrasound
Twisting force with the foot fixed on the ground seen in football and basketball games;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
35. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pure motor stroke; limited neurological dysfunction
36. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Less than 5mm
15-40%; self limiting;doesn't require tx
Subphrenic abscess or other abdominal abscesses; order US or CT
37. types of hip fracture
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Carpal tunnel syndrom
38. cat/dog bites
Amoxicillin-clavulanate
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
39. what size of ureteral stone for non op mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Ispilateral hypoglossal nerve injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Less than 5mm
40. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If patient ambulatory - surgery and pain control; if not nonop mx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
41. management of nondisplaced scaphoid fx
Retrograde ejaculation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Even after ochiopexy risk of ochiopexy higher then general population
42. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
50%; tunneling between rectum or kin
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Malignancy until proven otherwise
43. lacerated wound in palmer surface of hand. what structure is injured?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Tendons more likely
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
44. most common fx when falling on outsretched hand
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Even after ochiopexy risk of ochiopexy higher then general population
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
45. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Study showed no adverse effect; but they are contraindicated for PVD
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
46. SOB - confusion - petechial rash after trauma - fracture
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Carpal tunnel syndrom
47. stress fx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Klinefelter syndrome; 50 fold increase;
Fx displace >1mm - nonunion during followup - osteonecrosis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
48. Why right varicocele is more concerning?
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49. sudden onset of postoperative hyperglycemia when patient on TPN
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
50. how ABI help dx of PVD
Check ET tube placement if correct needle decompresion
S2-S4
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sorry!:) No result found.
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