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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. management of hip fracture
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
If patient ambulatory - surgery and pain control; if not nonop mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

2. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If patient ambulatory - surgery and pain control; if not nonop mx
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

3. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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;
CRPS
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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

4. how hyperventilation lowers ICP
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If patient ambulatory - surgery and pain control; if not nonop mx
15-40%; self limiting;doesn't require tx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

5. What is the contraindication of hyperventilation in inc ICP
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Headache - ataxia - bulbar dysfunction
Strok and traumatic brain injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

6. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Ispilateral hypoglossal nerve injury
Check ET tube placement if correct needle decompresion
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;

7. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

8. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
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;
Meniscus injury; medial most common; pain/swelling; popping sensation

9. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Nonunion and avascular necrosis; fx can block blood supply;
ACL injury

10. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Ispilateral hypoglossal nerve injury
Seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

11. when patient with severe lung disease have C02 retention
Next best step surgery; not ultrasound
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
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
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

12. 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
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 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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

13. 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
Mammogram
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
L5 to S2

14. indication of ursodeoxycholic acid
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
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
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

15. swelling and tenderness in anterior part of knee
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Patellar tendon tear; difficulty in extension
Headache - ataxia - bulbar dysfunction
Sphincter sparing surgery (local resection) - abdomnio perineal resection

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
ACL injury
SAH due to post communicating artery aneurysm;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Seminomas

17. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
ACL injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

18. management of gunshot wound
Check ET tube placement if correct needle decompresion
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
Retrograde ejaculation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

19. common complication of inadequate mx of scaphoid fx
Urethral stricture; pelvic of urethral trauma
Nonunion and avascular necrosis; fx can block blood supply;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. DD of acute scrotal pain
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
10-12 months
Carpal tunnel syndrom
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

21. how ABI help dx of PVD
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Study showed no adverse effect; but they are contraindicated for PVD

22. characteristics of ureteral stone?
If patient ambulatory - surgery and pain control; if not nonop mx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If any compressive symptoms eg. dysphagia

23. what size of ureteral stone for non op mx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Less than 5mm
Elevated non seminomas
4-6 weeks for noncontact sports and longer time for contact sports

24. When do we see complications due to hypophosphatemia
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;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
When urethral catherization is unsuccessful
Strok and traumatic brain injury

25. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
ACL injury
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

26. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Nonunion and avascular necrosis; fx can block blood supply;
50%; tunneling between rectum or kin
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

27. 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
Dm neuropathy; stocking glove pattern
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ampicillin sublactum - pipercillin - ceftriaxone and metro

28. Patient underwent CABG; postoperatively drowsy. most likely cause?
Next best step surgery; not ultrasound
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

29. Why right varicocele is more concerning?

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30. beta hcg and AFP
Patellar tendon tear; difficulty in extension
Pure motor stroke; limited neurological dysfunction
Elevated non seminomas
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

31. 3 mo with groin bulge; bulge appears when child cries
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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;
Supraglottic edema; low threshold for intubation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

32. managment of animal bite in hands
10-12 months
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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;

33. When goiter needs surgery
Seminomas
If any compressive symptoms eg. dysphagia
If patient ambulatory - surgery and pain control; if not nonop mx
L5 to S2

34. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Brardycardia - HTN - resp depression

35. Incidence of AF in CABG patient

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36. varicose veins with ulcer - bleeding and thrombophlebitits
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Next best step surgery; not ultrasound

37. How to evaluate painless testicular swelling suspicious for cancer
10-12 months
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports

38. inhalation of hot air - steam - smoke in burn victim
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

39. dorsiflexion and planter flexion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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;
L5 to S2

40. 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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
SAH due to post communicating artery aneurysm;

41. tx distal rectal ca
Patellar tendon tear; difficulty in extension
Progressive fibrosis of palmar fascia. etiololgy not known;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

42. several knee pain after being tackled in football game
Seminomas
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

43. How to differentiate ACL and meniscus injury
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

44. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check ET tube placement if correct needle decompresion
Amoxicillin-clavulanate
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. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
ACL injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Subphrenic abscess or other abdominal abscesses; order US or CT
Mammogram

46. management of stone 8-10mm
Low anterior resection and radio; add chemo if node positive
15-40%; self limiting;doesn't require tx
Tendons more likely
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

47. differential of ultrasound finding of breast mass
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

48. most frequent complication of TURP
If patient ambulatory - surgery and pain control; if not nonop mx
Check ET tube placement if correct needle decompresion
Study showed no adverse effect; but they are contraindicated for PVD
Retrograde ejaculation

49. What is cushing's triad
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Brardycardia - HTN - resp depression
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

50. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa