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Test your basic knowledge |
USMLE Step3 Surgery
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Study First
Subjects
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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. differential of ultrasound finding of breast mass
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
2. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Saline and silicone
50%; tunneling between rectum or kin
3. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4. several knee pain after being tackled in football game
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Brardycardia - HTN - resp depression
5. beta HCG
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;
6. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
24-48 hours of supportive therapy followed by cholecystectomy
Displaced ORIF ; nondisplaced sling immobilization
Carpal tunnel syndrom
7. Dupuytren contracture
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension
Progressive fibrosis of palmar fascia. etiololgy not known;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
8. tx distal rectal ca
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
9. 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
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
Progressive fibrosis of palmar fascia. etiololgy not known;
24-48 hours of supportive therapy followed by cholecystectomy
10. conservative Tx of varicose veins
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation
S2-S4
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
11. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Meniscus injury; medial most common; pain/swelling; popping sensation
S2-S4
12. inhalation of hot air - steam - smoke in burn victim
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Supraglottic edema; low threshold for intubation
13. cat/dog bites
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ispilateral hypoglossal nerve injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Amoxicillin-clavulanate
14. What types of breast implants are available
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Saline and silicone
15. What is the contraindication of hyperventilation in inc ICP
Mammogram
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Strok and traumatic brain injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
16. diarrhoea after gastric bypass
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mammogram
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dumping syndrome; small and frequent meals; no simple sugar
17. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
24-48 hours of supportive therapy followed by cholecystectomy
18. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Retrograde ejaculation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Patellar tendon tear; difficulty in extension
19. What is prehn sign?
Brardycardia - HTN - resp depression
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
20. pregnant patient with asymptomatic gall stones
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
21. management of stone 8-10mm
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Amoxicillin-clavulanate
22. lacerated wound in palmer surface of hand. what structure is injured?
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
Malignancy until proven otherwise
SAH due to post communicating artery aneurysm;
Tendons more likely
23. Why ruq calcificaion is concerning
Klinefelter syndrome; 50 fold increase;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
24. Why varicocele more common in the left side
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Check ET tube placement if correct needle decompresion
25. How varicocele causes testicular atrophy
If any compressive symptoms eg. dysphagia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Brardycardia - HTN - resp depression
26. What is cushing's triad
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Brardycardia - HTN - resp depression
Even after ochiopexy risk of ochiopexy higher then general population
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
27. dumping syndrome after gastrectomy
L5 to S2
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elderly and critically ill patients
28. Valgus and Varus tests
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
Nonunion and avascular necrosis; fx can block blood supply;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
29. management of gunshot wound
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
Study showed no adverse effect; but they are contraindicated for PVD
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Ampicillin sublactum - pipercillin - ceftriaxone and metro
30. How to evaluate painless testicular swelling suspicious for cancer
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cystic scrotal fluid collection between parietal and visceral layers of testis
Low anterior resection and radio; add chemo if node positive
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
31. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Displaced ORIF ; nondisplaced sling immobilization
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
32. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
33. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Strok and traumatic brain injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
SAH due to post communicating artery aneurysm;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
34. sudden onset of postoperative hyperglycemia when patient on TPN
Elderly and critically ill patients
Displaced ORIF ; nondisplaced sling immobilization
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;
35. SAH due to posterior inferior cerebellar aneurysm
Even after ochiopexy risk of ochiopexy higher then general population
Headache - ataxia - bulbar dysfunction
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
36. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
S2-S4
37. surgery for acute cholecystities
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
24-48 hours of supportive therapy followed by cholecystectomy
50%; tunneling between rectum or kin
38. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
When urethral catherization is unsuccessful
If any compressive symptoms eg. dysphagia
39. diarrhoea 4-5 days after cholecystectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
40. How to confirm achiles tendon rupture
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Amoxicillin-clavulanate
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
41. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Saline and silicone
Subphrenic abscess or other abdominal abscesses; order US or CT
Tendons more likely
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
42. perioral numbness after parathyroidectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
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
43. Why right varicocele is more concerning?
44. how hyperventilation lowers ICP
Unilateral vocal cord paralysis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Epi and chest compressio for prolong period of time; atropine is given after epi;
45. What is the complications of undescended testis
S2-S4
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Patellar tendon tear; difficulty in extension
Even after ochiopexy risk of ochiopexy higher then general population
46. What is hydrocele?
Compression stocking - weight reduction - leg elevation
24-48 hours of supportive therapy followed by cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
47. Patient underwent CABG; postoperatively drowsy. most likely cause?
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Carpal tunnel syndrom
Strok and traumatic brain injury
48. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Abd pain and tenderness; bloody diarrhoea or hematochezia
15-40%; self limiting;doesn't require tx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
49. contraindication of urethral catheterization
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Urethral stricture; pelvic of urethral trauma
Nonunion and avascular necrosis; fx can block blood supply;
50. Incidence of AF in CABG patient