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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. When patient can go back to sports after clavicle fx
Brardycardia - HTN - resp depression
4-6 weeks for noncontact sports and longer time for contact sports
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
50%; tunneling between rectum or kin

2. management of hip fracture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If patient ambulatory - surgery and pain control; if not nonop mx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
50%; tunneling between rectum or kin

3. 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;
Tendons more likely
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Compression stocking - weight reduction - leg elevation

4. mangement of localized lymphadenopathy
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
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

5. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
CRPS

6. cremasteric reflex
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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

7. How to manage a patient with asystole
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

8. Can we use beta blocker for pvd?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Study showed no adverse effect; but they are contraindicated for PVD
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

9. How to confirm dx of compartment syndrom
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Headache - ataxia - bulbar dysfunction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

10. Valgus and Varus tests
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

11. How to dx ACL tear?
When urethral catherization is unsuccessful
Elevated non seminomas
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

12. characteristics of ureteral stone?
Subphrenic abscess or other abdominal abscesses; order US or CT
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dumping syndrome; small and frequent meals; no simple sugar
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

13. when patient with severe lung disease have C02 retention
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
L5 to S2

14. common complication of inadequate mx of scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Nonunion and avascular necrosis; fx can block blood supply;
Subphrenic abscess or other abdominal abscesses; order US or CT
Dumping syndrome; small and frequent meals; no simple sugar

15. Most common of sudden death due to steering wheel injury
Seminomas
Compression stocking - weight reduction - leg elevation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

16. transrectal prostate biopsy
Retrograde ejaculation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
If any compressive symptoms eg. dysphagia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

17. cremasteric reflex test?
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Nonunion and avascular necrosis; fx can block blood supply;

18. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Elevated non seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

19. swelling and tenderness in anterior part of knee
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dm neuropathy; stocking glove pattern
Patellar tendon tear; difficulty in extension
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

20. How to evaluate painless testicular swelling suspicious for cancer
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Strok and traumatic brain injury

21. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

22. most frequent complication of TURP
Check ET tube placement if correct needle decompresion
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Retrograde ejaculation

23. menisci injury
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression
If any compressive symptoms eg. dysphagia
Twisting force with the foot fixed on the ground seen in football and basketball games;

24. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
4-6 weeks for noncontact sports and longer time for contact sports
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

25. aspiration of breast cyst is bloody
If patient ambulatory - surgery and pain control; if not nonop mx
SAH due to post communicating artery aneurysm;
Mammogram
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

26. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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 flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
S2-S4

27. What are the common injuries from lightning?
Nonunion and avascular necrosis; fx can block blood supply;
Even after ochiopexy risk of ochiopexy higher then general population
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

28. What is the contraindication of hyperventilation in inc ICP
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
CRPS
Strok and traumatic brain injury

29. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2

30. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

31. Incidence of AF in CABG patient

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32. acalculus cholecystitis
Dm neuropathy; stocking glove pattern
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Elderly and critically ill patients

33. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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 patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation
Check ET tube placement if correct needle decompresion

34. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

35. DD of acute scrotal pain
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

36. How to differentiate communicative and non-communicative hydrocele
Ispilateral hypoglossal nerve injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

37. how ABI help dx of PVD
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Less than 5mm
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

38. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Meniscus injury; medial most common; pain/swelling; popping sensation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

39. What types of breast implants are available
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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
Saline and silicone
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

40. Patient underwent CABG; postoperatively drowsy. most likely cause?
If patient ambulatory - surgery and pain control; if not nonop mx
Amoxicillin-clavulanate
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

41. ct scan; cystic lesion in head of pancreas; next step
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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.
Sphincter sparing surgery (local resection) - abdomnio perineal resection

42. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
10-12 months
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
When urethral catherization is unsuccessful

43. popping sensation; rapid onset of knee effusion. athelet
When urethral catherization is unsuccessful
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
If patient ambulatory - surgery and pain control; if not nonop mx

44. beta hcg and AFP
Unilateral vocal cord paralysis
Elevated non seminomas
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

45. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Carpal tunnel syndrom
Headache - ataxia - bulbar dysfunction

46. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
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

47. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

48. Why initial xrays are negative in scaphoid fx
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
15-40%; self limiting;doesn't require tx
24-48 hours of supportive therapy followed by cholecystectomy

49. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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 flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

50. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Unilateral vocal cord paralysis
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy