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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. Incidence of AF in CABG patient

2. dorsiflexion and planter flexion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Amoxicillin-clavulanate
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
L5 to S2

3. how hyperventilation lowers ICP
50%; tunneling between rectum or kin
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Carpal tunnel syndrom

4. diarrhoea after gastric bypass
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 any compressive symptoms eg. dysphagia
Dumping syndrome; small and frequent meals; no simple sugar
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

5. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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

6. complication displaced or communited distal radial fx
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
S2-S4
Carpal tunnel syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro

7. How to evaluate painless testicular swelling suspicious for cancer
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Ispilateral hypoglossal nerve injury
Pure motor stroke; limited neurological dysfunction

8. How varicocele causes testicular atrophy
Dumping syndrome; small and frequent meals; no simple sugar
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

9. How to differentiate ACL and meniscus injury
Carpal tunnel syndrom
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

10. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Seminomas
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

11. What types of breast implants are available
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Saline and silicone
Progressive fibrosis of palmar fascia. etiololgy not known;

12. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Fx displace >1mm - nonunion during followup - osteonecrosis
4-6 weeks for noncontact sports and longer time for contact sports
Mammogram

13. severe pain in leg after MVC
Klinefelter syndrome; 50 fold increase;
If patient ambulatory - surgery and pain control; if not nonop mx
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
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

14. acalculus cholecystitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

15. How to manage a patient with asystole
4-6 weeks for noncontact sports and longer time for contact sports
Brardycardia - HTN - resp depression
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Epi and chest compressio for prolong period of time; atropine is given after epi;

16. How to confirm dx of compartment syndrom
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
SAH due to post communicating artery aneurysm;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

17. When patient can go back to sports after clavicle fx
Elderly and critically ill patients
S2-S4
CRPS
4-6 weeks for noncontact sports and longer time for contact sports

18. several knee pain after being tackled in football game
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
Retrograde ejaculation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Carpal tunnel syndrom

19. stress fx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Check ET tube placement if correct needle decompresion
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cystic scrotal fluid collection between parietal and visceral layers of testis

20. varicose veins with ulcer - bleeding and thrombophlebitits
When urethral catherization is unsuccessful
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

21. scrotal trauma
Next best step surgery; not ultrasound
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

22. most common complication of acute cholecystitis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

23. 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
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Low anterior resection and radio; add chemo if node positive

24. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
50%; tunneling between rectum or kin
CRPS
Pure motor stroke; limited neurological dysfunction

25. management of stone 8-10mm
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Mammogram
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Compression stocking - weight reduction - leg elevation

26. aspiration of breast cyst is bloody
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mammogram
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

27. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Subphrenic abscess or other abdominal abscesses; order US or CT
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
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

28. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
SAH due to post communicating artery aneurysm;
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

29. What is the contraindication of hyperventilation in inc ICP
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

30. conservative Tx of varicose veins
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Compression stocking - weight reduction - leg elevation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro

31. first step for evaluation of testicular swelling
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Compression stocking - weight reduction - leg elevation

32. management of hip fracture
Even after ochiopexy risk of ochiopexy higher then general population
If patient ambulatory - surgery and pain control; if not nonop mx
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
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

33. first line of management of PVD
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Twisting force with the foot fixed on the ground seen in football and basketball games;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

34. prostate enlarged - nontender - no nodularity - elevated PSA
Fx displace >1mm - nonunion during followup - osteonecrosis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

35. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Fx displace >1mm - nonunion during followup - osteonecrosis
Brardycardia - HTN - resp depression
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

36. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
CRPS

37. most frequent complication of TURP
Retrograde ejaculation
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
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

38. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If any compressive symptoms eg. dysphagia
50%; tunneling between rectum or kin

39. What time frame required for bone remodeling
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
10-12 months
Increased size during the day and valsalva means it is communicated with peritoneal cavity

40. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

41. Why ruq calcificaion is concerning
Urethral stricture; pelvic of urethral trauma
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

42. Why initial xrays are negative in scaphoid fx
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Unilateral vocal cord paralysis

43. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Amoxicillin-clavulanate
Increased size during the day and valsalva means it is communicated with peritoneal cavity

44. diarrhoea 4-5 days after cholecystectomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Klinefelter syndrome; 50 fold increase;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

45. most common fx when falling on outsretched hand
Progressive fibrosis of palmar fascia. etiololgy not known;
50%; tunneling between rectum or kin
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased size during the day and valsalva means it is communicated with peritoneal cavity

46. What is hungry bone syndrome?
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

47. SAH due to posterior inferior cerebellar aneurysm
Retrograde ejaculation
Malignancy until proven otherwise
Headache - ataxia - bulbar dysfunction
Urethral stricture; pelvic of urethral trauma

48. What is most common lung injury after blunt chest trauma?
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
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
Study showed no adverse effect; but they are contraindicated for PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

49. dumping syndrome after gastrectomy
If patient ambulatory - surgery and pain control; if not nonop mx
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

50. painless testicular mass in young male
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;
Malignancy until proven otherwise
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion