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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. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pure motor stroke; limited neurological dysfunction
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

2. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Next best step surgery; not ultrasound
Tendons more likely
Klinefelter syndrome; 50 fold increase;
CRPS

3. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

4. dorsiflexion and planter flexion
Elevated non seminomas
L5 to S2
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pure motor stroke; limited neurological dysfunction

5. What is cushing's triad
Low anterior resection and radio; add chemo if node positive
Tendons more likely
Brardycardia - HTN - resp depression
Less than 5mm

6. What is hungry bone syndrome?
Next best step surgery; not ultrasound
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

7. dumping syndrome after gastrectomy
S2-S4
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

8. perioral numbness after parathyroidectomy
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Compression stocking - weight reduction - leg elevation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

9. menisci injury
Ispilateral hypoglossal nerve injury
If any compressive symptoms eg. dysphagia
Displaced ORIF ; nondisplaced sling immobilization
Twisting force with the foot fixed on the ground seen in football and basketball games;

10. when scaphoid fx patient needs to be referred to orthopedic
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Twisting force with the foot fixed on the ground seen in football and basketball games;
Fx displace >1mm - nonunion during followup - osteonecrosis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

11. What is prehn sign?
Retrograde ejaculation
15-40%; self limiting;doesn't require tx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

12. most common fx when falling on outsretched hand
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
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
Tendons more likely

13. antibiotics of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ampicillin sublactum - pipercillin - ceftriaxone and metro

14. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sphincter sparing surgery (local resection) - abdomnio perineal resection
When urethral catherization is unsuccessful

15. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dumping syndrome; small and frequent meals; no simple sugar
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dm neuropathy; stocking glove pattern

16. SOB - confusion - petechial rash after trauma - fracture
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
SAH due to post communicating artery aneurysm;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

17. ipsilateral deviation of tongue upon protrusion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Ispilateral hypoglossal nerve injury

18. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
ACL injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Check ET tube placement if correct needle decompresion

19. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Elevated non seminomas
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

20. What is the strongest risk factor for male breast cancer
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension
Klinefelter syndrome; 50 fold increase;

21. complication displaced or communited distal radial fx
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
Tendons more likely
Carpal tunnel syndrom
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

22. characteristics of ureteral stone?
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

23. What is hydrocele?
Meniscus injury; medial most common; pain/swelling; popping sensation
Cystic scrotal fluid collection between parietal and visceral layers of testis
4-6 weeks for noncontact sports and longer time for contact sports
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

24. first step for evaluation of testicular swelling
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2
Urethral stricture; pelvic of urethral trauma

25. How to dx ACL tear?
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
Displaced ORIF ; nondisplaced sling immobilization
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

26. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
24-48 hours of supportive therapy followed by cholecystectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

27. When goiter needs surgery
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
If any compressive symptoms eg. dysphagia
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

28. 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)
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

29. contraindication of urethral catheterization
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
Supraglottic edema; low threshold for intubation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Urethral stricture; pelvic of urethral trauma

30. cat/dog bites
Amoxicillin-clavulanate
Seminomas
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

31. Incidence of AF in CABG patient

32. How to evaluate painless testicular swelling suspicious for cancer
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Ampicillin sublactum - pipercillin - ceftriaxone and metro
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

33. first line of management of PVD
S2-S4
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; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

34. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

35. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
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
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

36. suprapubic catheterization
CRPS
When urethral catherization is unsuccessful
Patellar tendon tear; difficulty in extension
Brardycardia - HTN - resp depression

37. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Seminomas
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

38. midline neck swelling moves with protrusion of tongue
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

39. When patient can go back to sports after clavicle fx
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
4-6 weeks for noncontact sports and longer time for contact sports
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
If any compressive symptoms eg. dysphagia

40. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
If any compressive symptoms eg. dysphagia
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Meniscus injury; medial most common; pain/swelling; popping sensation

41. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
24-48 hours of supportive therapy followed by cholecystectomy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

42. How to manage obesity
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Progressive fibrosis of palmar fascia. etiololgy not known;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Low anterior resection and radio; add chemo if node positive

43. When do we see complications due to hypophosphatemia
Supraglottic edema; low threshold for intubation
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;
SAH due to post communicating artery aneurysm;
Saline and silicone

44. most common complication of acute cholecystitis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Compression stocking - weight reduction - leg elevation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis

45. beta hcg and AFP
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization

46. scrotal trauma
Next best step surgery; not ultrasound
Displaced ORIF ; nondisplaced sling immobilization
Mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity

47. how hyperventilation lowers ICP
If patient ambulatory - surgery and pain control; if not nonop mx
Ispilateral hypoglossal nerve injury
When urethral catherization is unsuccessful
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

48. lacunar stroke
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pure motor stroke; limited neurological dysfunction
CRPS
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

49. differential of ultrasound finding of breast mass
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Displaced ORIF ; nondisplaced sling immobilization
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

50. varicocele
Subphrenic abscess or other abdominal abscesses; order US or CT
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Nonunion and avascular necrosis; fx can block blood supply;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position