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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. characteristics of ureteral stone?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

2. surgery for acute cholecystities
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
Brardycardia - HTN - resp depression
If patient ambulatory - surgery and pain control; if not nonop mx

3. beta hcg and AFP
Elevated non seminomas
Strok and traumatic brain injury
Dumping syndrome; small and frequent meals; no simple sugar
Even after ochiopexy risk of ochiopexy higher then general population

4. When do we see complications due to hypophosphatemia
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
Supraglottic edema; low threshold for intubation

5. SOB - confusion - petechial rash after trauma - fracture
Malignancy until proven otherwise
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Meniscus injury; medial most common; pain/swelling; popping sensation
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

6. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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. mangement of localized lymphadenopathy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Supraglottic edema; low threshold for intubation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

8. Tx of pulmonary contusion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Displaced ORIF ; nondisplaced sling immobilization
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

9. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;

10. cat/dog bites
Amoxicillin-clavulanate
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

11. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Patellar tendon tear; difficulty in extension
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. Why right varicocele is more concerning?

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13. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
CRPS
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
Strok and traumatic brain injury

14. lacunar stroke
Pure motor stroke; limited neurological dysfunction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Mammogram

15. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

16. most common fx when falling on outsretched hand
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Patellar tendon tear; difficulty in extension
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

17. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Fx displace >1mm - nonunion during followup - osteonecrosis
Meniscus injury; medial most common; pain/swelling; popping sensation
Elevated non seminomas
S2-S4

18. ipsilateral deviation of tongue upon protrusion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Progressive fibrosis of palmar fascia. etiololgy not known;
Elderly and critically ill patients
Ispilateral hypoglossal nerve injury

19. How to manage obesity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Check ET tube placement if correct needle decompresion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

20. stress fx
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
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

21. pregnant patient with asymptomatic gall stones
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Mammogram
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

22. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Dm neuropathy; stocking glove pattern

23. What is the contraindication of hyperventilation in inc ICP
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
50%; tunneling between rectum or kin
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Strok and traumatic brain injury

24. Dupuytren contracture
Retrograde ejaculation
Progressive fibrosis of palmar fascia. etiololgy not known;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;

25. What types of breast implants are available
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Saline and silicone
SAH due to post communicating artery aneurysm;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

26. Incidence of AF in CABG patient

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27. management of hip fracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If patient ambulatory - surgery and pain control; if not nonop mx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

28. varicocele
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

29. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
50%; tunneling between rectum or kin

30. perioral numbness after parathyroidectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
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
S2-S4

31. acalculus cholecystitis
Elderly and critically ill patients
Dm neuropathy; stocking glove pattern
10-12 months
Tendons more likely

32. Most common of sudden death due to steering wheel injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Patellar tendon tear; difficulty in extension
Supraglottic edema; low threshold for intubation

33. transrectal prostate biopsy
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Next best step surgery; not ultrasound

34. Indication for bariatric surgery in obese patients
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;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dumping syndrome; small and frequent meals; no simple sugar
Elevated non seminomas

35. management of gunshot wound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Displaced ORIF ; nondisplaced sling immobilization
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

36. first step for evaluation of testicular swelling
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Brardycardia - HTN - resp depression
Check ET tube placement if correct needle decompresion
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

37. types of hip fracture
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

38. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Strok and traumatic brain injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
SAH due to post communicating artery aneurysm;

39. when patient with severe lung disease have C02 retention
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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 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

40. inhalation of hot air - steam - smoke in burn victim
CRPS
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Supraglottic edema; low threshold for intubation

41. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pure motor stroke; limited neurological dysfunction

42. varicose veins with ulcer - bleeding and thrombophlebitits
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

43. How varicocele causes testicular atrophy
10-12 months
L5 to S2
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Twisting force with the foot fixed on the ground seen in football and basketball games;

44. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
SAH due to post communicating artery aneurysm;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro

45. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

46. how ABI help dx of PVD
Progressive fibrosis of palmar fascia. etiololgy not known;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Retrograde ejaculation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

47. midline neck swelling moves with protrusion of tongue
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. aspiration of breast cyst is nonbloody
Mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

49. When patient can go back to sports after clavicle fx
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
4-6 weeks for noncontact sports and longer time for contact sports
If patient ambulatory - surgery and pain control; if not nonop mx
Next best step surgery; not ultrasound

50. scrotal trauma
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
Next best step surgery; not ultrasound
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Elevated non seminomas