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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. varicose veins with ulcer - bleeding and thrombophlebitits
Even after ochiopexy risk of ochiopexy higher then general population
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery

2. stress fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Supraglottic edema; low threshold for intubation
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;

3. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Less than 5mm
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

4. most frequent complication of TURP
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
Retrograde ejaculation
Pure motor stroke; limited neurological dysfunction
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

5. How to confirm dx of compartment syndrom
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

6. contraindication of urethral catheterization
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;
Urethral stricture; pelvic of urethral trauma
Supraglottic edema; low threshold for intubation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

7. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Elevated non seminomas
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

8. What is the contraindication of hyperventilation in inc ICP
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Meniscus injury; medial most common; pain/swelling; popping sensation
Strok and traumatic brain injury

9. 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;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Carpal tunnel syndrom
Study showed no adverse effect; but they are contraindicated for PVD

10. sudden onset of postoperative hyperglycemia when patient on TPN
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

11. aspiration of breast cyst is nonbloody
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

12. pregnant patient with asymptomatic gall stones
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

13. Most common of sudden death due to steering wheel injury
10-12 months
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

14. cremasteric reflex test?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Malignancy until proven otherwise

15. diarrhoea after gastric bypass
Progressive fibrosis of palmar fascia. etiololgy not known;
Dumping syndrome; small and frequent meals; no simple sugar
L5 to S2
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

16. popping sensation; rapid onset of knee effusion. athelet
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ACL injury
CRPS
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

17. Why initial xrays are negative in scaphoid fx
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Brardycardia - HTN - resp depression
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

18. complications of TPN
Next best step surgery; not ultrasound
Saline and silicone
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

19. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
4-6 weeks for noncontact sports and longer time for contact sports
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
50%; tunneling between rectum or kin

20. How to differentiate ACL and meniscus injury
Urethral stricture; pelvic of urethral trauma
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
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 any compressive symptoms eg. dysphagia

21. Incidence of AF in CABG patient

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22. what size of ureteral stone for non op mx
Low anterior resection and radio; add chemo if node positive
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Less than 5mm
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

23. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Subphrenic abscess or other abdominal abscesses; order US or CT
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
S2-S4

24. beta hcg and AFP
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Elevated non seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

25. perioral numbness after parathyroidectomy
Carpal tunnel syndrom
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

26. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
ACL injury
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

27. most common fx when falling on outsretched hand
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dm neuropathy; stocking glove pattern

28. 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
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Urethral stricture; pelvic of urethral trauma

29. SAH due to posterior inferior cerebellar aneurysm
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Headache - ataxia - bulbar dysfunction

30. What are the common injuries from lightning?
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pure motor stroke; limited neurological dysfunction
S2-S4

31. Why right varicocele is more concerning?

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32. indication of ursodeoxycholic acid
Progressive fibrosis of palmar fascia. etiololgy not known;
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;
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

33. What types of breast implants are available
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Headache - ataxia - bulbar dysfunction
Twisting force with the foot fixed on the ground seen in football and basketball games;
Saline and silicone

34. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Meniscus injury; medial most common; pain/swelling; popping sensation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

35. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Brardycardia - HTN - resp depression
Klinefelter syndrome; 50 fold increase;
Dm neuropathy; stocking glove pattern
Supraglottic edema; low threshold for intubation

36. management of gunshot wound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
L5 to S2

37. tx distal rectal ca
Saline and silicone
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

38. Tx of pulmonary contusion
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
SAH due to post communicating artery aneurysm;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

39. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Pure motor stroke; limited neurological dysfunction
Less than 5mm

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
S2-S4
SAH due to post communicating artery aneurysm;
Meniscus injury; medial most common; pain/swelling; popping sensation

41. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

42. What is hungry bone syndrome?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before 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
Pure motor stroke; limited neurological dysfunction
Elevated non seminomas

43. Dupuytren contracture
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Pure motor stroke; limited neurological dysfunction
Progressive fibrosis of palmar fascia. etiololgy not known;

44. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Klinefelter syndrome; 50 fold increase;
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

45. cat/dog bites
Amoxicillin-clavulanate
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Strok and traumatic brain injury

46. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Elderly and critically ill patients

47. antibiotics of acute cholecystitis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Patellar tendon tear; difficulty in extension
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

48. What is cushing's triad
Brardycardia - HTN - resp depression
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ACL injury
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;

49. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
50%; tunneling between rectum or kin
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Check ET tube placement if correct needle decompresion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

50. How to perform lachman test
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Klinefelter syndrome; 50 fold increase;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Saline and silicone