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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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check ET tube placement if correct needle decompresion

2. what size of ureteral stone for non op mx
Less than 5mm
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Strok and traumatic brain injury

3. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Cystic scrotal fluid collection between parietal and visceral layers of testis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
SAH due to post communicating artery aneurysm;

4. What types of breast implants are available
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Saline and silicone

5. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

6. How to differentiate communicative and non-communicative hydrocele
Progressive fibrosis of palmar fascia. etiololgy not known;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Twisting force with the foot fixed on the ground seen in football and basketball games;

7. suprapubic catheterization
Saline and silicone
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
When urethral catherization is unsuccessful
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

8. When do we see complications due to hypophosphatemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;
Even after ochiopexy risk of ochiopexy higher then general population

9. conservative Tx of varicose veins
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
Compression stocking - weight reduction - leg elevation
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

10. stress fx
SAH due to post communicating artery aneurysm;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Compression stocking - weight reduction - leg elevation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

11. scrotal trauma
Pure motor stroke; limited neurological dysfunction
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
Next best step surgery; not ultrasound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. When goiter needs surgery
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If any compressive symptoms eg. dysphagia

13. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Pure motor stroke; limited neurological dysfunction
Displaced ORIF ; nondisplaced sling immobilization
Subphrenic abscess or other abdominal abscesses; order US or CT

14. characteristics of ureteral stone?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Amoxicillin-clavulanate
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

15. aspiration of breast cyst is nonbloody
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

16. varicocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

17. prostate enlarged - nontender - no nodularity - elevated PSA
Supraglottic edema; low threshold for intubation
Subphrenic abscess or other abdominal abscesses; order US or CT
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Dm neuropathy; stocking glove pattern

18. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If any compressive symptoms eg. dysphagia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

19. complications of TPN
Less than 5mm
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

20. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

21. common complication of inadequate mx of scaphoid fx
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Nonunion and avascular necrosis; fx can block blood supply;
Progressive fibrosis of palmar fascia. etiololgy not known;

22. What is prehn sign?
Elevated non seminomas
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Brardycardia - HTN - resp depression
Patellar tendon tear; difficulty in extension

23. 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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

24. What is cushing's triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Brardycardia - HTN - resp depression
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Low anterior resection and radio; add chemo if node positive

25. When patient can go back to sports after clavicle fx
Malignancy until proven otherwise
Abd pain and tenderness; bloody diarrhoea or hematochezia
4-6 weeks for noncontact sports and longer time for contact sports
Less than 5mm

26. most common fx when falling on outsretched hand
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Check ET tube placement if correct needle decompresion
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

27. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

28. lacunar stroke
Amoxicillin-clavulanate
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pure motor stroke; limited neurological dysfunction
When urethral catherization is unsuccessful

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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

30. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Malignancy until proven otherwise
Unilateral vocal cord paralysis
Seminomas

31. How to dx ACL tear?
Low anterior resection and radio; add chemo if node positive
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
Subphrenic abscess or other abdominal abscesses; order US or CT
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

32. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

33. What is terrible triad
SAH due to post communicating artery aneurysm;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Tendons more likely
Mammogram

34. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

35. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Displaced ORIF ; nondisplaced sling immobilization
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

36. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
Patellar tendon tear; difficulty in extension
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. complication displaced or communited distal radial fx
Compression stocking - weight reduction - leg elevation
Cystic scrotal fluid collection between parietal and visceral layers of testis
Carpal tunnel syndrom
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

38. anal sphincter tone
Amoxicillin-clavulanate
S2-S4
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Next best step surgery; not ultrasound

39. cremasteric reflex
Pure motor stroke; limited neurological dysfunction
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dumping syndrome; small and frequent meals; no simple sugar

40. differential of ultrasound finding of breast mass
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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

41. How to manage a patient with asystole
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Epi and chest compressio for prolong period of time; atropine is given after epi;
Supraglottic edema; low threshold for intubation

42. first line of management of PVD
Strok and traumatic brain injury
CRPS
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

43. how ABI help dx of PVD
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Cystic scrotal fluid collection between parietal and visceral layers of testis

44. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Next best step surgery; not ultrasound
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

45. sudden onset of postoperative hyperglycemia when patient on TPN
Check ET tube placement if correct needle decompresion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Displaced ORIF ; nondisplaced sling immobilization
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

46. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Retrograde ejaculation
Brardycardia - HTN - resp depression
Dm neuropathy; stocking glove pattern
Twisting force with the foot fixed on the ground seen in football and basketball games;

47. severe pain in leg after MVC
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
S2-S4
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

48. How to evaluate painless testicular swelling suspicious for cancer
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

49. What percent of anal abscess deveolop fisutula
Malignancy until proven otherwise
50%; tunneling between rectum or kin
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
S2-S4

50. What is hungry bone syndrome?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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