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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. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Meniscus injury; medial most common; pain/swelling; popping sensation
Fx displace >1mm - nonunion during followup - osteonecrosis

2. characteristics of ureteral stone?
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Low anterior resection and radio; add chemo if node positive
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

3. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

4. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
10-12 months

5. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pure motor stroke; limited neurological dysfunction

6. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

7. diarrhoea 4-5 days after 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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Amoxicillin-clavulanate
Dm neuropathy; stocking glove pattern

8. How to confirm dx of compartment syndrom
Retrograde ejaculation
Unilateral vocal cord paralysis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

9. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

10. 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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Twisting force with the foot fixed on the ground seen in football and basketball games;
Strok and traumatic brain injury

11. Indication for bariatric surgery in obese patients
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;
Even after ochiopexy risk of ochiopexy higher then general population
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Next best step surgery; not ultrasound

13. beta hcg and AFP
SAH due to post communicating artery aneurysm;
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
Elevated non seminomas
Compression stocking - weight reduction - leg elevation

14. ipsilateral deviation of tongue upon protrusion
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
Ispilateral hypoglossal nerve injury
Less than 5mm
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

15. suprapubic catheterization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
When urethral catherization is unsuccessful
Unilateral vocal cord paralysis
If any compressive symptoms eg. dysphagia

16. diarrhoea after gastric bypass
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dumping syndrome; small and frequent meals; no simple sugar

17. Valgus and Varus tests
Dm neuropathy; stocking glove pattern
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

18. What are the common injuries from lightning?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

19. differential of ultrasound finding of breast mass
Study showed no adverse effect; but they are contraindicated for PVD
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
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

20. What is hydrocele?
24-48 hours of supportive therapy followed by cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

21. first line of management of PVD
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Klinefelter syndrome; 50 fold increase;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

22. acute colonic ischemia
Headache - ataxia - bulbar dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dm neuropathy; stocking glove pattern
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

23. perioral numbness after parathyroidectomy
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elevated non seminomas

24. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Malignancy until proven otherwise
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

25. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Brardycardia - HTN - resp depression

26. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Headache - ataxia - bulbar dysfunction
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
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
CRPS

27. When goiter needs surgery
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
If any compressive symptoms eg. dysphagia
Saline and silicone

28. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

29. several knee pain after being tackled in football game
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

30. DD of acute scrotal pain
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Saline and silicone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

31. beta HCG
Seminomas
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Subphrenic abscess or other abdominal abscesses; order US or CT
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

32. sudden onset of postoperative hyperglycemia when patient on TPN
Retrograde ejaculation
Check ET tube placement if correct needle decompresion
Malignancy until proven otherwise
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

33. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Abd pain and tenderness; bloody diarrhoea or hematochezia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Progressive fibrosis of palmar fascia. etiololgy not known;

34. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. scrotal trauma
Next best step surgery; not ultrasound
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Study showed no adverse effect; but they are contraindicated for PVD

36. What is the strongest risk factor for male breast cancer
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
ACL injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Klinefelter syndrome; 50 fold increase;

37. management of nondisplaced scaphoid fx
Carpal tunnel syndrom
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
SAH due to post communicating artery aneurysm;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

38. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
CRPS

39. how hyperventilation lowers ICP
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
4-6 weeks for noncontact sports and longer time for contact sports
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Headache - ataxia - bulbar dysfunction

40. most common fx when falling on outsretched hand
Elderly and critically ill patients
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Patellar tendon tear; difficulty in extension
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

41. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Klinefelter syndrome; 50 fold increase;
Dm neuropathy; stocking glove pattern
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;

42. when scaphoid fx patient needs to be referred to orthopedic
Supraglottic edema; low threshold for intubation
Fx displace >1mm - nonunion during followup - osteonecrosis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
S2-S4

43. popping sensation; rapid onset of knee effusion. athelet
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
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
ACL injury

44. What time frame required for bone remodeling
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
10-12 months
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

45. varicocele
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

46. What is cushing's triad
Brardycardia - HTN - resp depression
CRPS
Supraglottic edema; low threshold for intubation
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

47. mx of stress fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Next best step surgery; not ultrasound
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

48. dorsiflexion and planter flexion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
L5 to S2
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;
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

49. midline neck swelling moves with protrusion of tongue
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Ampicillin sublactum - pipercillin - ceftriaxone and metro

50. Tx of pulmonary contusion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Tendons more likely