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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?
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
Patellar tendon tear; difficulty in extension
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

2. surgery for acute cholecystities
Urethral stricture; pelvic of urethral trauma
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;
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months

3. beta hcg and AFP
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Elevated non seminomas

4. perioral numbness after parathyroidectomy
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
Carpal tunnel syndrom
Elevated non seminomas
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

5. SAH due to posterior inferior cerebellar aneurysm
Next best step surgery; not ultrasound
Headache - ataxia - bulbar dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Fx displace >1mm - nonunion during followup - osteonecrosis

6. diarrhoea 4-5 days after cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

7. How to dx ACL tear?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Meniscus injury; medial most common; pain/swelling; popping sensation

8. 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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fx displace >1mm - nonunion during followup - osteonecrosis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

9. management of stone 8-10mm
S2-S4
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

10. Tx of proximal non metastatic rectal ca
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Low anterior resection and radio; add chemo if node positive

11. dorsiflexion and planter flexion
L5 to S2
Headache - ataxia - bulbar dysfunction
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

12. common complication of inadequate mx of scaphoid fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Progressive fibrosis of palmar fascia. etiololgy not known;
Elevated non seminomas
Nonunion and avascular necrosis; fx can block blood supply;

13. Can we use beta blocker for pvd?
15-40%; self limiting;doesn't require tx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Malignancy until proven otherwise
Study showed no adverse effect; but they are contraindicated for PVD

14. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
SAH due to post communicating artery aneurysm;
Elevated non seminomas

15. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Meniscus injury; medial most common; pain/swelling; popping sensation
Strok and traumatic brain injury

16. suprapubic catheterization
When urethral catherization is unsuccessful
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

17. Dupuytren contracture
Unilateral vocal cord paralysis
When urethral catherization is unsuccessful
Progressive fibrosis of palmar fascia. etiololgy not known;
Tendons more likely

18. managment of animal bite in hands
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Retrograde ejaculation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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;

19. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Tendons more likely
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

20. several knee pain after being tackled in football game
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Check ET tube placement if correct needle decompresion

21. Why initial xrays are negative in scaphoid fx
Dm neuropathy; stocking glove pattern
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;
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
Seminomas

22. antibiotics of acute cholecystitis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

23. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Malignancy until proven otherwise
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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;

24. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Carpal tunnel syndrom
SAH due to post communicating artery aneurysm;

25. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Epi and chest compressio for prolong period of time; atropine is given after epi;
CRPS
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dm neuropathy; stocking glove pattern

26. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If patient ambulatory - surgery and pain control; if not nonop mx
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

27. lacerated wound in palmer surface of hand. what structure is injured?
15-40%; self limiting;doesn't require tx
Tendons more likely
Epi and chest compressio for prolong period of time; atropine is given after epi;
Brardycardia - HTN - resp depression

28. ipsilateral deviation of tongue upon protrusion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Ispilateral hypoglossal nerve injury
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
CRPS

29. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Strok and traumatic brain injury

30. anal sphincter tone
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports

31. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

32. What percent of anal abscess deveolop fisutula
Sphincter sparing surgery (local resection) - abdomnio perineal resection
50%; tunneling between rectum or kin
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
ACL injury

33. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Check ET tube placement if correct needle decompresion

34. pregnant patient with asymptomatic gall stones
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Carpal tunnel syndrom
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

35. When to do surgery in undesceneded testis?
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

36. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Subphrenic abscess or other abdominal abscesses; order US or CT
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
10-12 months

37. How to differentiate communicative and non-communicative hydrocele
Twisting force with the foot fixed on the ground seen in football and basketball games;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Carpal tunnel syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity

38. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Meniscus injury; medial most common; pain/swelling; popping sensation
Low anterior resection and radio; add chemo if node positive
Patellar tendon tear; difficulty in extension

39. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Mammogram
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

40. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Meniscus injury; medial most common; pain/swelling; popping sensation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

41. Indication for bariatric surgery in obese patients
Check ET tube placement if correct needle decompresion
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
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole

42. severe pain in leg after MVC
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Sphincter sparing surgery (local resection) - abdomnio perineal resection

43. diarrhoea after gastric bypass
SAH due to post communicating artery aneurysm;
Dumping syndrome; small and frequent meals; no simple sugar
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Pure motor stroke; limited neurological dysfunction
If patient ambulatory - surgery and pain control; if not nonop mx
Urethral stricture; pelvic of urethral trauma

45. painless testicular mass in young male
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Malignancy until proven otherwise
Nonunion and avascular necrosis; fx can block blood supply;
S2-S4

46. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If patient ambulatory - surgery and pain control; if not nonop mx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dm neuropathy; stocking glove pattern

47. tx distal rectal ca
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Sphincter sparing surgery (local resection) - abdomnio perineal resection

48. SOB - confusion - petechial rash after trauma - fracture
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
15-40%; self limiting;doesn't require tx
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

49. contraindication of urethral catheterization
Displaced ORIF ; nondisplaced sling immobilization
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Patellar tendon tear; difficulty in extension
Urethral stricture; pelvic of urethral trauma

50. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous