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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. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Check ET tube placement if correct needle decompresion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

2. mx of stress fx
Strok and traumatic brain injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

3. lacerated wound in palmer surface of hand. what structure is injured?
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;
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
Tendons more likely
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;

4. inhalation of hot air - steam - smoke in burn victim
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Supraglottic edema; low threshold for intubation
Study showed no adverse effect; but they are contraindicated for PVD
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

5. surgery for acute cholecystities
Patellar tendon tear; difficulty in extension
50%; tunneling between rectum or kin
24-48 hours of supportive therapy followed by cholecystectomy
Pure motor stroke; limited neurological dysfunction

6. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Compression stocking - weight reduction - leg elevation
4-6 weeks for noncontact sports and longer time for contact sports
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

7. beta hcg and AFP
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If any compressive symptoms eg. dysphagia
Carpal tunnel syndrom
Elevated non seminomas

8. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
50%; tunneling between rectum or kin

9. painless testicular mass in young male
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Malignancy until proven otherwise
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

10. When do we see complications due to hypophosphatemia
Progressive fibrosis of palmar fascia. etiololgy not known;
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
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;
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

11. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

12. 3 mo with groin bulge; bulge appears when child cries
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Next best step surgery; not ultrasound
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

13. ct scan; cystic lesion in head of pancreas; next step
Progressive fibrosis of palmar fascia. etiololgy not known;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

14. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Study showed no adverse effect; but they are contraindicated for PVD
4-6 weeks for noncontact sports and longer time for contact sports

15. Most common of sudden death due to steering wheel injury
Saline and silicone
Brardycardia - HTN - resp depression
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

16. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
15-40%; self limiting;doesn't require tx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
4-6 weeks for noncontact sports and longer time for contact sports
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

17. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Check ET tube placement if correct needle decompresion
When urethral catherization is unsuccessful

18. contraindication of urethral catheterization
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Urethral stricture; pelvic of urethral trauma
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

19. managment of animal bite in hands
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
Even after ochiopexy risk of ochiopexy higher then general population
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;
Klinefelter syndrome; 50 fold increase;

20. dorsiflexion and planter flexion
Mammogram
L5 to S2
Saline and silicone
Sphincter sparing surgery (local resection) - abdomnio perineal resection

21. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

22. How to confirm achiles tendon rupture
Saline and silicone
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
Next best step surgery; not ultrasound

23. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If any compressive symptoms eg. dysphagia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Even after ochiopexy risk of ochiopexy higher then general population

24. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Amoxicillin-clavulanate
Low anterior resection and radio; add chemo if node positive
Seminomas

25. mangement of localized lymphadenopathy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

26. differential of ultrasound finding of breast mass
Patellar tendon tear; difficulty in extension
Ispilateral hypoglossal nerve injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

27. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Malignancy until proven otherwise
Elevated non seminomas
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

28. What is the strongest risk factor for male breast cancer
Even after ochiopexy risk of ochiopexy higher then general population
24-48 hours of supportive therapy followed by cholecystectomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Klinefelter syndrome; 50 fold increase;

29. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

30. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Dm neuropathy; stocking glove pattern
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

31. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

32. management of stone 8-10mm
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 patient ambulatory - surgery and pain control; if not nonop mx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Strok and traumatic brain injury

33. What is cushing's triad
Seminomas
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Brardycardia - HTN - resp depression
If patient ambulatory - surgery and pain control; if not nonop mx

34. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

35. transrectal prostate biopsy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
When urethral catherization is unsuccessful
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

36. Why varicocele more common in the left side
Saline and silicone
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

37. Dupuytren contracture
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Progressive fibrosis of palmar fascia. etiololgy not known;

38. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

39. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ispilateral hypoglossal nerve injury
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

40. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Urethral stricture; pelvic of urethral trauma
S2-S4
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

41. When goiter needs surgery
Nonunion and avascular necrosis; fx can block blood supply;
Low anterior resection and radio; add chemo if node positive
If any compressive symptoms eg. dysphagia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

42. management of hip fracture
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
Epi and chest compressio for prolong period of time; atropine is given after epi;
Next best step surgery; not ultrasound

43. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Mammogram

44. antibiotics of acute cholecystitis
CRPS
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

45. What is hungry bone syndrome?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Klinefelter syndrome; 50 fold increase;
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
Compression stocking - weight reduction - leg elevation

46. What percent of anal abscess deveolop fisutula
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
50%; tunneling between rectum or kin
L5 to S2
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

47. Can we use beta blocker for pvd?
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
Elderly and critically ill patients
Study showed no adverse effect; but they are contraindicated for PVD
Seminomas

48. How mcmurray manuver perform
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dumping syndrome; small and frequent meals; no simple sugar
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

49. 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
Low anterior resection and radio; add chemo if node positive
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Elderly and critically ill patients

50. How to manage a patient with asystole
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur