Test your basic knowledge |

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. 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;
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
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

2. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Brardycardia - HTN - resp depression
Next best step surgery; not ultrasound
Carpal tunnel syndrom

3. lacerated wound in palmer surface of hand. what structure is injured?
Malignancy until proven otherwise
Tendons more likely
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
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

4. Dupuytren contracture
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;
Retrograde ejaculation
Progressive fibrosis of palmar fascia. etiololgy not known;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

5. several knee pain after being tackled in football game
Carpal tunnel syndrom
If any compressive symptoms eg. dysphagia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

6. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Mammogram
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

7. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound 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
Mammogram

8. acute colonic ischemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
SAH due to post communicating artery aneurysm;
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

9. managment of animal bite in hands
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Twisting force with the foot fixed on the ground seen in football and basketball games;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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. anal sphincter tone
S2-S4
Less than 5mm
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

11. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

12. 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
Displaced ORIF ; nondisplaced sling immobilization
15-40%; self limiting;doesn't require tx
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

13. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Amoxicillin-clavulanate
Nonunion and avascular necrosis; fx can block blood supply;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

14. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Progressive fibrosis of palmar fascia. etiololgy not known;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

15. dorsiflexion and planter flexion
ACL injury
Elevated non seminomas
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
L5 to S2

16. antibiotics of acute cholecystitis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Compression stocking - weight reduction - leg elevation
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Amoxicillin-clavulanate

17. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dm neuropathy; stocking glove pattern
Low anterior resection and radio; add chemo if node positive
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

18. Tx of pulmonary contusion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
L5 to S2
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

19. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

20. first line of management of PVD
CRPS
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;

21. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Urethral stricture; pelvic of urethral trauma

22. How mcmurray manuver perform
Even after ochiopexy risk of ochiopexy higher then general population
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Brardycardia - HTN - resp depression

23. When patient can go back to sports after clavicle fx
Brardycardia - HTN - resp depression
SAH due to post communicating artery aneurysm;
Mammogram
4-6 weeks for noncontact sports and longer time for contact sports

24. What is the contraindication of hyperventilation in inc ICP
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports

25. SAH due to posterior inferior cerebellar aneurysm
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Headache - ataxia - bulbar dysfunction
Subphrenic abscess or other abdominal abscesses; order US or CT

26. When to do surgery in undesceneded testis?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
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

28. types of hip fracture
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
Saline and silicone
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

29. ipsilateral deviation of tongue upon protrusion
ACL injury
Ispilateral hypoglossal nerve injury
Elderly and critically ill patients
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

30. 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;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
ACL injury
Malignancy until proven otherwise

31. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

32. Can we use beta blocker for pvd?
Tendons more likely
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Study showed no adverse effect; but they are contraindicated for PVD
Ampicillin sublactum - pipercillin - ceftriaxone and metro

33. When goiter needs surgery
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If any compressive symptoms eg. dysphagia
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

34. suprapubic catheterization
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful
Unilateral vocal cord paralysis

35. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

36. mangement of localized lymphadenopathy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

37. management of hip fracture
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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 patient ambulatory - surgery and pain control; if not nonop mx
Ampicillin sublactum - pipercillin - ceftriaxone and metro

38. prostate enlarged - nontender - no nodularity - elevated PSA
Urethral stricture; pelvic of urethral trauma
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Unilateral vocal cord paralysis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

39. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
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
Elevated non seminomas

40. How to perform lachman test
Seminomas
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Meniscus injury; medial most common; pain/swelling; popping sensation
Epi and chest compressio for prolong period of time; atropine is given after epi;

41. 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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

42. How to confirm dx of compartment syndrom
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Displaced ORIF ; nondisplaced sling immobilization
Malignancy until proven otherwise
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

43. sudden onset of postoperative hyperglycemia when patient on TPN
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

44. ct scan; cystic lesion in head of pancreas; next step
Brardycardia - HTN - resp depression
Klinefelter syndrome; 50 fold increase;
If patient ambulatory - surgery and pain control; if not nonop mx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

45. tx distal rectal ca
Brardycardia - HTN - resp depression
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sphincter sparing surgery (local resection) - abdomnio perineal resection

46. 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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
ACL injury
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

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
4-6 weeks for noncontact sports and longer time for contact sports
Headache - ataxia - bulbar dysfunction
Increased size during the day and valsalva means it is communicated with peritoneal cavity

48. What percent of anal abscess deveolop fisutula
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
50%; tunneling between rectum or kin
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

49. painless testicular mass in young male
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Malignancy until proven otherwise
Patellar tendon tear; difficulty in extension
Next best step surgery; not ultrasound

50. Patient underwent CABG; postoperatively drowsy. most likely cause?
Malignancy until proven otherwise
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis
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