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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. lacunar stroke
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pure motor stroke; limited neurological dysfunction
Tendons more likely

2. dumping syndrome after gastrectomy
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Tendons more likely
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Ampicillin sublactum - pipercillin - ceftriaxone and metro

3. How to dx ACL tear?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

4. Incidence of AF in CABG patient

5. How to manage obesity
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

6. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

7. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

8. when patient with severe lung disease have C02 retention
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
24-48 hours of supportive therapy followed by cholecystectomy
ACL injury

9. stress fx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

10. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

11. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Check ET tube placement if correct needle decompresion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

12. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Epi and chest compressio for prolong period of time; atropine is given after epi;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
S2-S4

13. Tx of pulmonary contusion
15-40%; self limiting;doesn't require tx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
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

14. menisci injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
24-48 hours of supportive therapy followed by cholecystectomy
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

15. tx distal rectal ca
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Check ET tube placement if correct needle decompresion
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

16. How to confirm achiles tendon rupture
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
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

17. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

18. most common complication of acute cholecystitis
Seminomas
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

19. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

20. Why right varicocele is more concerning?

21. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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;
Supraglottic edema; low threshold for intubation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

22. What is the complications of undescended testis
Nonunion and avascular necrosis; fx can block blood supply;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Even after ochiopexy risk of ochiopexy higher then general population
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;

23. dorsiflexion and planter flexion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
L5 to S2

24. management of nondisplaced scaphoid fx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. when scaphoid fx patient needs to be referred to orthopedic
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Fx displace >1mm - nonunion during followup - osteonecrosis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

26. What time frame required for bone remodeling
Tendons more likely
Strok and traumatic brain injury
10-12 months
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

27. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Subphrenic abscess or other abdominal abscesses; order US or CT
Mammogram

28. what size of ureteral stone for non op mx
Less than 5mm
Low anterior resection and radio; add chemo if node positive
L5 to S2
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

29. contraindication of urethral catheterization
If any compressive symptoms eg. dysphagia
Compression stocking - weight reduction - leg elevation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Urethral stricture; pelvic of urethral trauma

30. how hyperventilation lowers ICP
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.
L5 to S2
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

31. Most common of sudden death due to steering wheel 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;
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

32. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

33. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

34. When patient can go back to sports after clavicle fx
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;
Study showed no adverse effect; but they are contraindicated for PVD
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
4-6 weeks for noncontact sports and longer time for contact sports

35. midline neck swelling moves with protrusion of tongue
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;

36. What types of breast implants are available
Saline and silicone
Urethral stricture; pelvic of urethral trauma
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

37. diarrhoea 4-5 days after cholecystectomy
Abd pain and tenderness; bloody diarrhoea or hematochezia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

38. Dupuytren contracture
If patient ambulatory - surgery and pain control; if not nonop mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Progressive fibrosis of palmar fascia. etiololgy not known;
Dumping syndrome; small and frequent meals; no simple sugar

39. differential of ultrasound finding of breast mass
Check ET tube placement if correct needle decompresion
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

40. What is cushing's triad
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Less than 5mm
Brardycardia - HTN - resp depression

41. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Supraglottic edema; low threshold for intubation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. scrotal trauma
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Next best step surgery; not ultrasound
Malignancy until proven otherwise

43. cremasteric reflex test?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Next best step surgery; not ultrasound
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

44. common complication of inadequate mx of scaphoid fx
Check ET tube placement if correct needle decompresion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Nonunion and avascular necrosis; fx can block blood supply;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

45. management of hip fracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If patient ambulatory - surgery and pain control; if not nonop mx
L5 to S2
ACL injury

46. severe pain in leg after MVC
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
Saline and silicone
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

47. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Low anterior resection and radio; add chemo if node positive
Subphrenic abscess or other abdominal abscesses; order US or CT

48. What is the contraindication of hyperventilation in inc ICP
4-6 weeks for noncontact sports and longer time for contact sports
Strok and traumatic brain injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

49. several knee pain after being tackled in football game
SAH due to post communicating artery aneurysm;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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;

50. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins