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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
Amoxicillin-clavulanate
CRPS
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

2. how hyperventilation lowers ICP
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

3. diarrhoea after gastric bypass
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
Amoxicillin-clavulanate
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dumping syndrome; small and frequent meals; no simple sugar

4. How varicocele causes testicular atrophy
Elderly and critically ill patients
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Compression stocking - weight reduction - leg elevation
Meniscus injury; medial most common; pain/swelling; popping sensation

5. Why right varicocele is more concerning?

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6. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia

7. 3 mo with groin bulge; bulge appears when child cries
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Ispilateral hypoglossal nerve injury
Pure motor stroke; limited neurological dysfunction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

8. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Even after ochiopexy risk of ochiopexy higher then general population
Urethral stricture; pelvic of urethral trauma

9. sudden onset of postoperative hyperglycemia when patient on TPN
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
S2-S4
Check ET tube placement if correct needle decompresion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

10. most common complication of acute cholecystitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Compression stocking - weight reduction - leg elevation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

11. When to stop raloxifene before surgery
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
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
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. xray finding of stress fx after 3-4w
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

13. clavicle fx
Check ET tube placement if correct needle decompresion
Meniscus injury; medial most common; pain/swelling; popping sensation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Displaced ORIF ; nondisplaced sling immobilization

14. What is cushing's triad
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
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;
Brardycardia - HTN - resp depression

15. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Meniscus injury; medial most common; pain/swelling; popping sensation
Klinefelter syndrome; 50 fold increase;

16. 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;
Saline and silicone
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Displaced ORIF ; nondisplaced sling immobilization

17. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
24-48 hours of supportive therapy followed by cholecystectomy

18. severe pain in leg after MVC
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

19. aspiration of breast cyst is bloody
Elderly and critically ill patients
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mammogram
S2-S4

20. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Nonunion and avascular necrosis; fx can block blood supply;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

21. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Compression stocking - weight reduction - leg elevation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

22. conservative Tx of varicose veins
SAH due to post communicating artery aneurysm;
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;
Compression stocking - weight reduction - leg elevation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

23. Incidence of AF in CABG patient

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24. when patient with severe lung disease have C02 retention
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
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
Strok and traumatic brain injury
Patellar tendon tear; difficulty in extension

25. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Less than 5mm
Klinefelter syndrome; 50 fold increase;

26. acute colonic ischemia
15-40%; self limiting;doesn't require tx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

27. characteristics of ureteral stone?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

28. beta hcg and AFP
Seminomas
Elevated non seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

29. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elevated non seminomas
Carpal tunnel syndrom

30. first step for evaluation of testicular swelling
Klinefelter syndrome; 50 fold increase;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Subphrenic abscess or other abdominal abscesses; order US or CT

31. beta HCG
Mammogram
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Seminomas
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

32. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Tendons more likely
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)

33. How to confirm dx of compartment syndrom
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

34. cremasteric reflex
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Displaced ORIF ; nondisplaced sling immobilization
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

35. What time frame required for bone remodeling
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
10-12 months
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Seminomas

36. suprapubic catheterization
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
When urethral catherization is unsuccessful
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

37. most common fx when falling on outsretched hand
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

38. scrotal trauma
Dm neuropathy; stocking glove pattern
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Next best step surgery; not ultrasound

39. indication of ursodeoxycholic acid
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
Ispilateral hypoglossal nerve injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Next best step surgery; not ultrasound

40. Why initial xrays are negative in scaphoid fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
ACL injury
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

41. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Meniscus injury; medial most common; pain/swelling; popping sensation
Malignancy until proven otherwise

42. contraindication of urethral catheterization
Headache - ataxia - bulbar dysfunction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Urethral stricture; pelvic of urethral trauma
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

43. acalculus cholecystitis
Saline and silicone
Elderly and critically ill patients
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

44. Tx of pulmonary contusion
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Study showed no adverse effect; but they are contraindicated for PVD
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

45. ct scan; cystic lesion in head of pancreas; next step
Pure motor stroke; limited neurological dysfunction
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;
L5 to S2
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

46. antibiotics of acute cholecystitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

47. DD of acute scrotal pain
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

48. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma
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
24-48 hours of supportive therapy followed by cholecystectomy

49. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

50. popping sensation; rapid onset of knee effusion. athelet
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein