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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. suprapubic catheterization
Less than 5mm
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
When urethral catherization is unsuccessful
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

2. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Cystic scrotal fluid collection between parietal and visceral layers of testis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Displaced ORIF ; nondisplaced sling immobilization

3. scrotal trauma
Less than 5mm
Next best step surgery; not ultrasound
Fx displace >1mm - nonunion during followup - osteonecrosis
ACL injury

4. anal sphincter tone
15-40%; self limiting;doesn't require tx
S2-S4
Tendons more likely
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

5. midline neck swelling moves with protrusion of tongue
Ispilateral hypoglossal nerve injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

6. Valgus and Varus tests
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Meniscus injury; medial most common; pain/swelling; popping sensation

7. How to manage obesity
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

8. varicose veins with ulcer - bleeding and thrombophlebitits
Displaced ORIF ; nondisplaced sling immobilization
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Headache - ataxia - bulbar dysfunction

9. beta HCG
Check ET tube placement if correct needle decompresion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Seminomas
Carpal tunnel syndrom

10. dorsiflexion and planter flexion
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

11. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cystic scrotal fluid collection between parietal and visceral layers of testis

12. management of stone 8-10mm
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

13. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Klinefelter syndrome; 50 fold increase;
ACL injury
Meniscus injury; medial most common; pain/swelling; popping sensation

14. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Retrograde ejaculation

15. popping sensation; rapid onset of knee effusion. athelet
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
ACL injury
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

16. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Unilateral vocal cord paralysis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

17. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

18. first line of management of PVD
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

19. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

20. How to dx ACL tear?
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

21. What time frame required for bone remodeling
10-12 months
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dumping syndrome; small and frequent meals; no simple sugar

22. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Malignancy until proven otherwise
Brardycardia - HTN - resp depression
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

23. DD of acute scrotal pain
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection

24. What is the strongest risk factor for male breast cancer
Less than 5mm
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Low anterior resection and radio; add chemo if node positive
Klinefelter syndrome; 50 fold increase;

25. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Progressive fibrosis of palmar fascia. etiololgy not known;
SAH due to post communicating artery aneurysm;
Elderly and critically ill patients
Dm neuropathy; stocking glove pattern

26. Tx of pulmonary contusion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
ACL injury
Patellar tendon tear; difficulty in extension
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

27. mx of stress fx
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Strok and traumatic brain injury

29. How to confirm achiles tendon rupture
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
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;
L5 to S2

30. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
S2-S4
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

31. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

32. painless testicular mass in young male
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Malignancy until proven otherwise
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

33. What is hungry bone syndrome?
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
SAH due to post communicating artery aneurysm;
Unilateral vocal cord paralysis
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

34. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
S2-S4

35. clavicle fx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Displaced ORIF ; nondisplaced sling immobilization

36. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
10-12 months

37. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Increased size during the day and valsalva means it is communicated with peritoneal cavity
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

38. beta hcg and AFP
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If any compressive symptoms eg. dysphagia
Elevated non seminomas
Cystic scrotal fluid collection between parietal and visceral layers of testis

39. ipsilateral deviation of tongue upon protrusion
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ispilateral hypoglossal nerve injury
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
If any compressive symptoms eg. dysphagia

40. SOB - confusion - petechial rash after trauma - fracture
Saline and silicone
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

42. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. management of nondisplaced scaphoid fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
CRPS
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

44. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If any compressive symptoms eg. dysphagia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

45. what size of ureteral stone for non op mx
Low anterior resection and radio; add chemo if node positive
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant 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;
Less than 5mm

46. Incidence of AF in CABG patient

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47. Why ruq calcificaion is concerning
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Less than 5mm
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

48. When goiter needs surgery
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Saline and silicone
If any compressive symptoms eg. dysphagia

49. transrectal prostate biopsy
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

50. acalculus cholecystitis
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
Elderly and critically ill patients
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elevated non seminomas