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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. How to perform lachman test
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
SAH due to post communicating artery aneurysm;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

2. inhalation of hot air - steam - smoke in burn victim
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Supraglottic edema; low threshold for intubation
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
Check ET tube placement if correct needle decompresion

3. Why ruq calcificaion is concerning
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Unilateral vocal cord paralysis
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. When to stop raloxifene before surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. DD of acute scrotal pain
ACL injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

6. aspiration of breast cyst is bloody
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
Elderly and critically ill patients
Mammogram
If patient ambulatory - surgery and pain control; if not nonop mx

7. Can we use beta blocker for pvd?
Elderly and critically ill patients
Study showed no adverse effect; but they are contraindicated for PVD
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

8. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
L5 to S2

9. surgery for acute cholecystities
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
24-48 hours of supportive therapy followed by cholecystectomy
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

10. cremasteric reflex
4-6 weeks for noncontact sports and longer time for contact sports
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Low anterior resection and radio; add chemo if node positive

11. clavicle fx
50%; tunneling between rectum or kin
Displaced ORIF ; nondisplaced sling immobilization
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Retrograde ejaculation

12. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Compression stocking - weight reduction - leg elevation
Meniscus injury; medial most common; pain/swelling; popping sensation

13. How to confirm achiles tendon rupture
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
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check ET tube placement if correct needle decompresion

14. suprapubic catheterization
When urethral catherization is unsuccessful
Dm neuropathy; stocking glove pattern
If any compressive symptoms eg. dysphagia
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

15. complication displaced or communited distal radial fx
Carpal tunnel syndrom
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
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

16. when patient with severe lung disease have C02 retention
Fx displace >1mm - nonunion during followup - osteonecrosis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

17. SAH due to posterior inferior cerebellar aneurysm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
Headache - ataxia - bulbar dysfunction

18. several knee pain after being tackled in football game
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
24-48 hours of supportive therapy followed by cholecystectomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

19. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sphincter sparing surgery (local resection) - abdomnio perineal resection

20. What are the common injuries from lightning?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Fx displace >1mm - nonunion during followup - osteonecrosis

21. menisci injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Twisting force with the foot fixed on the ground seen in football and basketball games;

22. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Dm neuropathy; stocking glove pattern
10-12 months
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

23. Complications of breast impant
Mammogram
Displaced ORIF ; nondisplaced sling immobilization
When urethral catherization is unsuccessful
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

24. How to confirm dx of compartment syndrom
Retrograde ejaculation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Carpal tunnel syndrom
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Cystic scrotal fluid collection between parietal and visceral layers of testis

26. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;

27. most common complication of acute cholecystitis
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
Pure motor stroke; limited neurological dysfunction
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

28. When to do surgery in undesceneded testis?
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
Seminomas
When urethral catherization is unsuccessful
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

29. When patient can go back to sports after clavicle fx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Fx displace >1mm - nonunion during followup - osteonecrosis
4-6 weeks for noncontact sports and longer time for contact sports
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

30. beta hcg and AFP
Check ET tube placement if correct needle decompresion
Elevated non seminomas
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

31. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
SAH due to post communicating artery aneurysm;
Subphrenic abscess or other abdominal abscesses; order US or CT
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

32. What is terrible triad
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

33. cat/dog bites
Low anterior resection and radio; add chemo if node positive
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Amoxicillin-clavulanate
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

34. lacunar stroke
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Mammogram
Pure motor stroke; limited neurological dysfunction

35. What time frame required for bone remodeling
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months
Pure motor stroke; limited neurological dysfunction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

36. scrotal trauma
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;
Next best step surgery; not ultrasound
SAH due to post communicating artery aneurysm;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

37. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

38. How to evaluate painless testicular swelling suspicious for cancer
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

39. prostate enlarged - nontender - no nodularity - elevated PSA
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

40. xray finding of stress fx after 3-4w
15-40%; self limiting;doesn't require tx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Even after ochiopexy risk of ochiopexy higher then general population

41. What is hydrocele?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cystic scrotal fluid collection between parietal and visceral layers of testis

42. complications of TPN
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
24-48 hours of supportive therapy followed by cholecystectomy

43. beta HCG
Strok and traumatic brain injury
Malignancy until proven otherwise
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Seminomas

44. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Abd pain and tenderness; bloody diarrhoea or hematochezia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

45. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
SAH due to post communicating artery aneurysm;
Supraglottic edema; low threshold for intubation

46. characteristics of ureteral stone?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

47. How to differentiate ACL and meniscus injury
Check ET tube placement if correct needle decompresion
Amoxicillin-clavulanate
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

48. severe pain in leg after MVC
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

49. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

50. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Study showed no adverse effect; but they are contraindicated for PVD