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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. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

2. Incidence of AF in CABG patient

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3. What is hungry bone syndrome?
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Elevated non seminomas

4. acalculus cholecystitis
Carpal tunnel syndrom
Next best step surgery; not ultrasound
Elderly and critically ill patients
Study showed no adverse effect; but they are contraindicated for PVD

5. common complication of inadequate mx of scaphoid fx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Nonunion and avascular necrosis; fx can block blood supply;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

6. Tx of pulmonary contusion
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;
If any compressive symptoms eg. dysphagia

7. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
50%; tunneling between rectum or kin
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

8. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

9. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Amoxicillin-clavulanate

10. diarrhoea 4-5 days after cholecystectomy
Mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

11. cremasteric reflex
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Twisting force with the foot fixed on the ground seen in football and basketball games;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

12. What are the common injuries from lightning?
Brardycardia - HTN - resp depression
4-6 weeks for noncontact sports and longer time for contact sports
Mammogram
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

13. transrectal prostate biopsy
Urethral stricture; pelvic of urethral trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

14. What is most common lung injury after blunt chest trauma?
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
15-40%; self limiting;doesn't require tx

15. dorsiflexion and planter flexion
Twisting force with the foot fixed on the ground seen in football and basketball games;
L5 to S2
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Even after ochiopexy risk of ochiopexy higher then general population
S2-S4
Dm neuropathy; stocking glove pattern
Subphrenic abscess or other abdominal abscesses; order US or CT

17. surgery for acute cholecystities
Check ET tube placement if correct needle decompresion
24-48 hours of supportive therapy followed by cholecystectomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

18. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Amoxicillin-clavulanate
Progressive fibrosis of palmar fascia. etiololgy not known;

19. complication displaced or communited distal radial fx
Malignancy until proven otherwise
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;
Carpal tunnel syndrom

20. When goiter needs surgery
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If any compressive symptoms eg. dysphagia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

21. beta hcg and AFP
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
Elevated non seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

22. How to manage obesity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Subphrenic abscess or other abdominal abscesses; order US or CT
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

23. diarrhoea after gastric bypass
If any compressive symptoms eg. dysphagia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dumping syndrome; small and frequent meals; no simple sugar

24. acute colonic ischemia
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;
Pure motor stroke; limited neurological dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abd pain and tenderness; bloody diarrhoea or hematochezia

25. characteristics of ureteral stone?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Seminomas
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

26. menisci injury
Amoxicillin-clavulanate
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
When urethral catherization is unsuccessful

27. severe pain in leg after MVC
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
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;
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

28. suprapubic catheterization
If patient ambulatory - surgery and pain control; if not nonop mx
When urethral catherization is unsuccessful
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

29. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Less than 5mm
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Elderly and critically ill patients

30. types of hip fracture
4-6 weeks for noncontact sports and longer time for contact sports
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
SAH due to post communicating artery aneurysm;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

31. prostate enlarged - nontender - no nodularity - elevated PSA
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Supraglottic edema; low threshold for intubation

32. anal sphincter tone
24-48 hours of supportive therapy followed by cholecystectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
S2-S4

33. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
15-40%; self limiting;doesn't require tx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Twisting force with the foot fixed on the ground seen in football and basketball games;

34. When patient can go back to sports after clavicle fx
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports
Mammogram
Pure motor stroke; limited neurological dysfunction

35. When to do surgery in undesceneded testis?
50%; tunneling between rectum or kin
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

36. Complications of breast impant
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

37. What is cushing's triad
Meniscus injury; medial most common; pain/swelling; popping sensation
Elevated non seminomas
Brardycardia - HTN - resp depression
Mammogram

38. most frequent complication of TURP
Retrograde ejaculation
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;
Even after ochiopexy risk of ochiopexy higher then general population
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

39. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation

40. Can we use beta blocker for pvd?
Fx displace >1mm - nonunion during followup - osteonecrosis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

41. scrotal trauma
Displaced ORIF ; nondisplaced sling immobilization
10-12 months
Unilateral vocal cord paralysis
Next best step surgery; not ultrasound

42. differential of ultrasound finding of breast mass
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
4-6 weeks for noncontact sports and longer time for contact sports
Compression stocking - weight reduction - leg elevation

43. what size of ureteral stone for non op mx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Less than 5mm
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. How mcmurray manuver perform
Supraglottic edema; low threshold for intubation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

45. varicose veins with ulcer - bleeding and thrombophlebitits
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Unilateral vocal cord paralysis

46. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

47. How to differentiate communicative and non-communicative hydrocele
MAT; medial meniscus injury; ACL and Tibial colateral ligament
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

48. inhalation of hot air - steam - smoke in burn victim
Low anterior resection and radio; add chemo if node positive
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Supraglottic edema; low threshold for intubation

49. Why ruq calcificaion is concerning
Epi and chest compressio for prolong period of time; atropine is given after epi;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Tendons more likely
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

50. management of nondisplaced scaphoid fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal