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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. What is hungry bone syndrome?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

2. cremasteric reflex test?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dumping syndrome; small and frequent meals; no simple sugar
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

3. What types of breast implants are available
Saline and silicone
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
ACL injury
Progressive fibrosis of palmar fascia. etiololgy not known;

4. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Patellar tendon tear; difficulty in extension
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

5. Can we use beta blocker for pvd?
Less than 5mm
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
Klinefelter syndrome; 50 fold increase;

6. Why varicocele more common in the left side
24-48 hours of supportive therapy followed by cholecystectomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Retrograde ejaculation
Elevated non seminomas

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

8. what size of ureteral stone for non op mx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Carpal tunnel syndrom
SAH due to post communicating artery aneurysm;
Less than 5mm

9. Why initial xrays are negative in scaphoid fx
Meniscus injury; medial most common; pain/swelling; popping sensation
Elderly and critically ill patients
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

10. When patient can go back to sports after clavicle fx
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
Progressive fibrosis of palmar fascia. etiololgy not known;
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
4-6 weeks for noncontact sports and longer time for contact sports

11. SAH due to posterior inferior cerebellar aneurysm
Twisting force with the foot fixed on the ground seen in football and basketball games;
Headache - ataxia - bulbar dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sphincter sparing surgery (local resection) - abdomnio perineal resection

12. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Ispilateral hypoglossal nerve injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

13. management of nondisplaced scaphoid 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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Seminomas
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

14. managment of animal bite in hands
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
When urethral catherization is unsuccessful

15. Why right varicocele is more concerning?

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16. swelling and tenderness in anterior part of knee
Seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Patellar tendon tear; difficulty in extension
24-48 hours of supportive therapy followed by cholecystectomy

17. 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
Carpal tunnel syndrom
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

18. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Mammogram
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

19. mangement of localized lymphadenopathy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Meniscus injury; medial most common; pain/swelling; popping sensation
15-40%; self limiting;doesn't require tx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

20. suprapubic catheterization
When urethral catherization is unsuccessful
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

21. Incidence of AF in CABG patient

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22. severe pain in leg after MVC
10-12 months
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
Dumping syndrome; small and frequent meals; no simple sugar
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

23. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Urethral stricture; pelvic of urethral trauma
Dumping syndrome; small and frequent meals; no simple sugar
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

24. aspiration of breast cyst is bloody
4-6 weeks for noncontact sports and longer time for contact sports
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

25. perioral numbness after parathyroidectomy
Urethral stricture; pelvic of urethral trauma
Nonunion and avascular necrosis; fx can block blood supply;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

26. What time frame required for bone remodeling
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
10-12 months
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

27. Most common of sudden death due to steering wheel injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
ACL injury

28. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Check ET tube placement if correct needle decompresion
4-6 weeks for noncontact sports and longer time for contact sports
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

29. types of hip fracture
Headache - ataxia - bulbar dysfunction
Less than 5mm
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

30. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Compression stocking - weight reduction - leg elevation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

31. contraindication of urethral catheterization
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Urethral stricture; pelvic of urethral trauma

32. when scaphoid fx patient needs to be referred to orthopedic
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis
Less than 5mm

33. tx distal rectal ca
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Sphincter sparing surgery (local resection) - abdomnio perineal resection
50%; tunneling between rectum or kin
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

34. When do we see complications due to hypophosphatemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
Klinefelter syndrome; 50 fold increase;

35. most common complication of acute cholecystitis
Tendons more likely
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Unilateral vocal cord paralysis

36. antibiotics of acute cholecystitis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Even after ochiopexy risk of ochiopexy higher then general population

37. clavicle fx
Meniscus injury; medial most common; pain/swelling; popping sensation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dumping syndrome; small and frequent meals; no simple sugar
Displaced ORIF ; nondisplaced sling immobilization

38. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Carpal tunnel syndrom
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
Subphrenic abscess or other abdominal abscesses; order US or CT

39. prostate enlarged - nontender - no nodularity - elevated PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

40. recurrent laryngeal nerve injury
Ispilateral hypoglossal nerve injury
S2-S4
Unilateral vocal cord paralysis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

41. acalculus cholecystitis
Elderly and critically ill patients
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament

42. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

43. varicocele
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Study showed no adverse effect; but they are contraindicated for PVD
Strok and traumatic brain injury

44. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Retrograde ejaculation
When urethral catherization is unsuccessful

45. most common fx when falling on outsretched hand
Meniscus injury; medial most common; pain/swelling; popping sensation
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
50%; tunneling between rectum or kin

47. Complications of breast impant
Less than 5mm
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

48. Why ruq calcificaion is concerning
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

49. What is most common lung injury after blunt chest trauma?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Abd pain and tenderness; bloody diarrhoea or hematochezia

50. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
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