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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 most common lung injury after blunt chest trauma?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Low anterior resection and radio; add chemo if node positive
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

2. Indication for bariatric surgery in obese patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;
Brardycardia - HTN - resp depression
Amoxicillin-clavulanate

3. beta HCG
Fx displace >1mm - nonunion during followup - osteonecrosis
Seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

4. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Elderly and critically ill patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

5. most common complication of acute cholecystitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;

6. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;

7. How mcmurray manuver perform
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Epi and chest compressio for prolong period of time; atropine is given after epi;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

8. How to evaluate painless testicular swelling suspicious for cancer
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

9. How varicocele causes testicular atrophy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Klinefelter syndrome; 50 fold increase;
Progressive fibrosis of palmar fascia. etiololgy not known;

10. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
15-40%; self limiting;doesn't require tx
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. 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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

12. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
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
Elevated non seminomas
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

13. types of hip fracture
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

14. contraindication of urethral catheterization
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Urethral stricture; pelvic of urethral trauma
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

15. How to confirm achiles tendon rupture
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
Study showed no adverse effect; but they are contraindicated for PVD
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

16. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
24-48 hours of supportive therapy followed by cholecystectomy
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

17. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Compression stocking - weight reduction - leg elevation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

18. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Subphrenic abscess or other abdominal abscesses; order US or CT

19. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Supraglottic edema; low threshold for intubation
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

20. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Brardycardia - HTN - resp depression
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

21. aspiration of breast cyst is bloody
Mammogram
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Elderly and critically ill patients
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

22. recurrent laryngeal nerve injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Unilateral vocal cord paralysis
50%; tunneling between rectum or kin

23. menisci injury
Dumping syndrome; small and frequent meals; no simple sugar
Unilateral vocal cord paralysis
15-40%; self limiting;doesn't require tx
Twisting force with the foot fixed on the ground seen in football and basketball games;

24. What is cushing's triad
Brardycardia - HTN - resp depression
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Subphrenic abscess or other abdominal abscesses; order US or CT
Study showed no adverse effect; but they are contraindicated for PVD

25. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Saline and silicone
50%; tunneling between rectum or kin
Unilateral vocal cord paralysis

26. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

27. 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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
24-48 hours of supportive therapy followed by cholecystectomy
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

28. antibiotics of acute cholecystitis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Study showed no adverse effect; but they are contraindicated for PVD
Saline and silicone
Ampicillin sublactum - pipercillin - ceftriaxone and metro

29. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
4-6 weeks for noncontact sports and longer time for contact sports
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

30. cat/dog bites
Amoxicillin-clavulanate
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

31. What is terrible triad
SAH due to post communicating artery aneurysm;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

32. conservative Tx of varicose veins
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Compression stocking - weight reduction - leg elevation
Check ET tube placement if correct needle decompresion

33. first step for evaluation of testicular swelling
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

34. dumping syndrome after gastrectomy
Less than 5mm
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

35. Complications of breast impant
Seminomas
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

36. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Strok and traumatic brain injury

37. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Meniscus injury; medial most common; pain/swelling; popping sensation
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

38. Why initial xrays are negative in 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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

39. 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
Elevated non seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

40. several knee pain after being tackled in football game
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Check ET tube placement if correct needle decompresion

41. Why right varicocele is more concerning?

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42. 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;
Study showed no adverse effect; but they are contraindicated for PVD
Compression stocking - weight reduction - leg elevation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

43. sudden onset of postoperative hyperglycemia when patient on TPN
Brardycardia - HTN - resp depression
SAH due to post communicating artery aneurysm;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

44. Why varicocele more common in the left side
If any compressive symptoms eg. dysphagia
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Cystic scrotal fluid collection between parietal and visceral layers of testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament

45. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis

46. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Headache - ataxia - bulbar dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

47. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
Supraglottic edema; low threshold for intubation
Epi and chest compressio for prolong period of time; atropine is given after epi;

48. acalculus cholecystitis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elderly and critically ill patients

49. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Carpal tunnel syndrom
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
CRPS

50. what size of ureteral stone for non op mx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Saline and silicone
Less than 5mm
Study showed no adverse effect; but they are contraindicated for PVD