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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. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
If any compressive symptoms eg. dysphagia
Displaced ORIF ; nondisplaced sling immobilization
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check ET tube placement if correct needle decompresion

2. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Dumping syndrome; small and frequent meals; no simple sugar
S2-S4
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

3. mx of stress fx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ispilateral hypoglossal nerve injury
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

4. characteristics of ureteral stone?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
S2-S4
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

5. What is cushing's triad
Carpal tunnel syndrom
Brardycardia - HTN - resp depression
10-12 months
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

6. Complications of breast impant
Check ET tube placement if correct needle decompresion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

7. acute colonic ischemia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
SAH due to post communicating artery aneurysm;
50%; tunneling between rectum or kin
Abd pain and tenderness; bloody diarrhoea or hematochezia

8. When patient can go back to sports after clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
4-6 weeks for noncontact sports and longer time for contact sports

9. antibiotics of acute cholecystitis
Tendons more likely
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Displaced ORIF ; nondisplaced sling immobilization
Ampicillin sublactum - pipercillin - ceftriaxone and metro

10. Indication for bariatric surgery in obese patients
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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;

11. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Carpal tunnel syndrom
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

12. menisci injury
Tendons more likely
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Saline and silicone

13. diarrhoea after gastric bypass
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dumping syndrome; small and frequent meals; no simple sugar
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

14. what size of ureteral stone for non op mx
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
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
24-48 hours of supportive therapy followed by cholecystectomy
Less than 5mm

15. clavicle fx
Compression stocking - weight reduction - leg elevation
Study showed no adverse effect; but they are contraindicated for PVD
Displaced ORIF ; nondisplaced sling immobilization
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

16. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Carpal tunnel syndrom
S2-S4
Subphrenic abscess or other abdominal abscesses; order US or CT

17. anal sphincter tone
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
Elevated non seminomas
S2-S4
If any compressive symptoms eg. dysphagia

18. when scaphoid fx patient needs to be referred to orthopedic
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Fx displace >1mm - nonunion during followup - osteonecrosis
Supraglottic edema; low threshold for intubation

19. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Meniscus injury; medial most common; pain/swelling; popping sensation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Abd pain and tenderness; bloody diarrhoea or hematochezia

20. most frequent complication of TURP
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Epi and chest compressio for prolong period of time; atropine is given after epi;
Retrograde ejaculation
Less than 5mm

21. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Saline and silicone

22. differential of ultrasound finding of breast mass
Amoxicillin-clavulanate
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Tendons more likely

23. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dumping syndrome; small and frequent meals; no simple sugar

24. What time frame required for bone remodeling
Study showed no adverse effect; but they are contraindicated for PVD
10-12 months
S2-S4
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

25. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

26. How to perform lachman test
Urethral stricture; pelvic of urethral trauma
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Klinefelter syndrome; 50 fold increase;

27. management of nondisplaced scaphoid fx
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Compression stocking - weight reduction - leg elevation

28. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Low anterior resection and radio; add chemo if node positive

29. Why right varicocele is more concerning?

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30. beta hcg and AFP
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
24-48 hours of supportive therapy followed by cholecystectomy
Elevated non seminomas
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

31. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Patellar tendon tear; difficulty in extension
Displaced ORIF ; nondisplaced sling immobilization

32. What is hydrocele?
Subphrenic abscess or other abdominal abscesses; order US or CT
Cystic scrotal fluid collection between parietal and visceral layers of testis
Supraglottic edema; low threshold for intubation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

33. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Supraglottic edema; low threshold for intubation
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

34. How to manage obesity
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

35. painless testicular mass in young male
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Malignancy until proven otherwise
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
Supraglottic edema; low threshold for intubation

36. 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)
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;
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 patient ambulatory - surgery and pain control; if not nonop mx

37. complications of TPN
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

38. What is hungry bone syndrome?
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Seminomas
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;

39. prostate enlarged - nontender - no nodularity - elevated PSA
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
L5 to S2
Malignancy until proven otherwise

40. 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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

41. cremasteric reflex
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

42. When to stop raloxifene before surgery
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Compression stocking - weight reduction - leg elevation
Check ET tube placement if correct needle decompresion

43. recurrent laryngeal nerve injury
Displaced ORIF ; nondisplaced sling immobilization
Unilateral vocal cord paralysis
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

44. transrectal prostate biopsy
Low anterior resection and radio; add chemo if node positive
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
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

45. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Elevated non seminomas

46. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Subphrenic abscess or other abdominal abscesses; order US or CT
Elevated non seminomas
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

47. management of stone 8-10mm
Carpal tunnel syndrom
Saline and silicone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

48. What is the strongest risk factor for male breast cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Klinefelter syndrome; 50 fold increase;
Study showed no adverse effect; but they are contraindicated for PVD
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

49. surgery for acute cholecystities
Tendons more likely
SAH due to post communicating artery aneurysm;
24-48 hours of supportive therapy followed by cholecystectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

50. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Headache - ataxia - bulbar dysfunction
Mammogram