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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. beta HCG
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Epi and chest compressio for prolong period of time; atropine is given after epi;
Seminomas

2. what size of ureteral stone for non op mx
Subphrenic abscess or other abdominal abscesses; order US or CT
Less than 5mm
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

3. most common fx when falling on outsretched hand
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Klinefelter syndrome; 50 fold increase;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

4. What is most common lung injury after blunt chest trauma?
Supraglottic edema; low threshold for intubation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

5. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Elderly and critically ill patients
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

6. management of nondisplaced scaphoid fx
10-12 months
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elevated non seminomas
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

7. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Elevated non seminomas
4-6 weeks for noncontact sports and longer time for contact sports
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

8. What is terrible triad
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Strok and traumatic brain injury

9. when scaphoid fx patient needs to be referred to orthopedic
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Fx displace >1mm - nonunion during followup - osteonecrosis
Patellar tendon tear; difficulty in extension

10. xray finding of stress fx after 3-4w
10-12 months
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
MAT; medial meniscus injury; ACL and Tibial colateral ligament

11. cat/dog bites
Amoxicillin-clavulanate
Next best step surgery; not ultrasound
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. What is the strongest risk factor for male breast cancer
ACL injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Progressive fibrosis of palmar fascia. etiololgy not known;
Klinefelter syndrome; 50 fold increase;

13. antibiotics of acute cholecystitis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Headache - ataxia - bulbar dysfunction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Ampicillin sublactum - pipercillin - ceftriaxone and metro

14. prostate enlarged - nontender - no nodularity - elevated PSA
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;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

15. Indication for bariatric surgery in obese patients
When urethral catherization is unsuccessful
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
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

16. ct scan; cystic lesion in head of pancreas; next step
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Ispilateral hypoglossal nerve injury
SAH due to post communicating artery aneurysm;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

17. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Strok and traumatic brain injury
Study showed no adverse effect; but they are contraindicated for PVD
Meniscus injury; medial most common; pain/swelling; popping sensation

18. transrectal prostate biopsy
50%; tunneling between rectum or kin
Saline and silicone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

19. What percent of anal abscess deveolop fisutula
Klinefelter syndrome; 50 fold increase;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
50%; tunneling between rectum or kin
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

20. acute colonic ischemia
ACL injury
Malignancy until proven otherwise
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abd pain and tenderness; bloody diarrhoea or hematochezia

21. What time frame required for bone remodeling
10-12 months
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
Compression stocking - weight reduction - leg elevation

22. Tx of pulmonary contusion
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

23. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
SAH due to post communicating artery aneurysm;

24. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

25. management of gunshot wound
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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)
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

26. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

27. anal sphincter tone
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sphincter sparing surgery (local resection) - abdomnio perineal resection
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
S2-S4

28. dorsiflexion and planter flexion
L5 to S2
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
24-48 hours of supportive therapy followed by cholecystectomy
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

29. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Next best step surgery; not ultrasound
Saline and silicone
Increased size during the day and valsalva means it is communicated with peritoneal cavity

30. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;

31. What is the complications of undescended testis
Next best step surgery; not ultrasound
Fx displace >1mm - nonunion during followup - osteonecrosis
Even after ochiopexy risk of ochiopexy higher then general population
15-40%; self limiting;doesn't require tx

32. 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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

33. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Saline and silicone
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

34. characteristics of ureteral stone?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
ACL injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

35. midline neck swelling moves with protrusion of tongue
Twisting force with the foot fixed on the ground seen in football and basketball games;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Compression stocking - weight reduction - leg elevation

36. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

37. types of hip fracture
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mammogram
Brardycardia - HTN - resp depression
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

38. cremasteric reflex
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

39. DD of acute scrotal pain
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;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elevated non seminomas

40. lacunar stroke
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
4-6 weeks for noncontact sports and longer time for contact sports
Pure motor stroke; limited neurological dysfunction
ACL injury

41. dumping syndrome after gastrectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Retrograde ejaculation

42. surgery for acute cholecystities
Mammogram
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
24-48 hours of supportive therapy followed by cholecystectomy
ACL injury

43. 3 mo with groin bulge; bulge appears when child cries
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
CRPS

44. aspiration of breast cyst is bloody
Mammogram
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

45. management of hip fracture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If patient ambulatory - surgery and pain control; if not nonop mx
Supraglottic edema; low threshold for intubation

46. Why initial xrays are negative in scaphoid fx
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;
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
Elderly and critically ill patients
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

47. Tx of proximal non metastatic rectal ca
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia
Low anterior resection and radio; add chemo if node positive
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;

48. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Nonunion and avascular necrosis; fx can block blood supply;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

49. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Twisting force with the foot fixed on the ground seen in football and basketball games;

50. What is the contraindication of hyperventilation in inc ICP
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Strok and traumatic brain injury