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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 are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Strok and traumatic brain injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sphincter sparing surgery (local resection) - abdomnio perineal resection

2. management of hip fracture
Seminomas
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation

3. scrotal trauma
Next best step surgery; not ultrasound
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Amoxicillin-clavulanate
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

4. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
24-48 hours of supportive therapy followed by cholecystectomy
Strok and traumatic brain injury
10-12 months

5. Most common of sudden death due to steering wheel injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Twisting force with the foot fixed on the ground seen in football and basketball games;

6. What time frame required for bone remodeling
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

7. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
50%; tunneling between rectum or kin
Low anterior resection and radio; add chemo if node positive
When urethral catherization is unsuccessful
Check ET tube placement if correct needle decompresion

8. suprapubic catheterization
When urethral catherization is unsuccessful
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

9. ipsilateral deviation of tongue upon protrusion
Elderly and critically ill patients
Ispilateral hypoglossal nerve injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

10. menisci injury
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Twisting force with the foot fixed on the ground seen in football and basketball games;
Saline and silicone

11. What is the contraindication of hyperventilation in inc ICP
If patient ambulatory - surgery and pain control; if not nonop mx
Strok and traumatic brain injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elevated non seminomas

12. cat/dog bites
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Saline and silicone
Next best step surgery; not ultrasound
Amoxicillin-clavulanate

13. tx distal rectal ca
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sphincter sparing surgery (local resection) - abdomnio perineal resection

14. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Tendons more likely
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Saline and silicone

15. How to manage obesity
Epi and chest compressio for prolong period of time; atropine is given after epi;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ACL injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

16. severe pain in leg after MVC
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
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
CRPS
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

17. Tx of pulmonary contusion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Urethral stricture; pelvic of urethral trauma
Even after ochiopexy risk of ochiopexy higher then general population

18. When to do surgery in undesceneded testis?
Elevated non seminomas
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;

19. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

20. what size of ureteral stone for non op mx
Less than 5mm
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
Meniscus injury; medial most common; pain/swelling; popping sensation

21. varicose veins with ulcer - bleeding and thrombophlebitits
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Pure motor stroke; limited neurological dysfunction

22. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Displaced ORIF ; nondisplaced sling immobilization
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
CRPS
Dm neuropathy; stocking glove pattern

23. What types of breast implants are available
Saline and silicone
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Check ET tube placement if correct needle decompresion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

24. Patient underwent CABG; postoperatively drowsy. most likely cause?
S2-S4
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before 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 injury; medial most common; pain/swelling; popping sensation

25. How to manage a patient with asystole
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Epi and chest compressio for prolong period of time; atropine is given after epi;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dm neuropathy; stocking glove pattern

26. dumping syndrome after gastrectomy
Nonunion and avascular necrosis; fx can block blood supply;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If any compressive symptoms eg. dysphagia

27. lacerated wound in palmer surface of hand. what structure is injured?
When urethral catherization is unsuccessful
Subphrenic abscess or other abdominal abscesses; order US or CT
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Tendons more likely

28. popping sensation; rapid onset of knee effusion. athelet
Epi and chest compressio for prolong period of time; atropine is given after epi;
ACL injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

29. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Dm neuropathy; stocking glove pattern
Tendons more likely
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. What is the strongest risk factor for male breast cancer
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Klinefelter syndrome; 50 fold increase;
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

31. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Subphrenic abscess or other abdominal abscesses; order US or CT
Brardycardia - HTN - resp depression
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

32. How mcmurray manuver perform
Strok and traumatic brain injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Tendons more likely

33. beta hcg and AFP
Elevated non seminomas
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

34. acute colonic ischemia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Carpal tunnel syndrom
Abd pain and tenderness; bloody diarrhoea or hematochezia
Saline and silicone

35. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

36. 27 yo with scrotal mass; warm tender testes feel like bag of worms
15-40%; self limiting;doesn't require tx
4-6 weeks for noncontact sports and longer time for contact sports
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

37. diarrhoea 4-5 days after cholecystectomy
Twisting force with the foot fixed on the ground seen in football and basketball games;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

38. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
Unilateral vocal cord paralysis
24-48 hours of supportive therapy followed by cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

39. contraindication of urethral catheterization
ACL injury
Urethral stricture; pelvic of urethral trauma
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Even after ochiopexy risk of ochiopexy higher then general population

40. How to dx ACL tear?
Elderly and critically ill patients
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

41. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

42. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dm neuropathy; stocking glove pattern
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
L5 to S2

43. 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
Nonunion and avascular necrosis; fx can block blood supply;
Dumping syndrome; small and frequent meals; no simple sugar
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

44. mx of stress fx
Brardycardia - HTN - resp depression
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

45. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

46. Tx of proximal non metastatic rectal ca
Cystic scrotal fluid collection between parietal and visceral layers of testis
Low anterior resection and radio; add chemo if node positive
Progressive fibrosis of palmar fascia. etiololgy not known;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

47. managment of animal bite in hands
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;
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;
Less than 5mm

48. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
CRPS
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

49. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
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;
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;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

50. How to confirm dx of compartment syndrom
Headache - ataxia - bulbar dysfunction
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy