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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. midline neck swelling moves with protrusion of tongue
L5 to S2
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

2. aspiration of breast cyst is nonbloody
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
50%; tunneling between rectum or kin
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Twisting force with the foot fixed on the ground seen in football and basketball games;

3. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Nonunion and avascular necrosis; fx can block blood supply;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

4. acute colonic ischemia
Dumping syndrome; small and frequent meals; no simple sugar
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

5. most frequent complication of TURP
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Retrograde ejaculation
Urethral stricture; pelvic of urethral trauma
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

6. anal sphincter tone
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
Carpal tunnel syndrom
S2-S4

7. types of hip fracture
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension
Headache - ataxia - bulbar dysfunction

8. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

9. several knee pain after being tackled in football game
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ACL injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

10. ipsilateral deviation of tongue upon protrusion
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Ispilateral hypoglossal nerve injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

11. management of stone 8-10mm
24-48 hours of supportive therapy followed by cholecystectomy
Low anterior resection and radio; add chemo if node positive
<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

12. Patient underwent CABG; postoperatively drowsy. most likely cause?
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Strok and traumatic brain injury
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

13. perioral numbness after parathyroidectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

14. How to differentiate ACL and meniscus injury
Patellar tendon tear; difficulty in extension
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

15. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elevated non seminomas
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4-6 weeks for noncontact sports and longer time for contact sports

16. how hyperventilation lowers ICP
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Meniscus injury; medial most common; pain/swelling; popping sensation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Patellar tendon tear; difficulty in extension

17. What is the contraindication of hyperventilation in inc ICP
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Strok and traumatic brain injury
If any compressive symptoms eg. dysphagia

18. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

19. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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)
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

20. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
CRPS
Dumping syndrome; small and frequent meals; no simple sugar
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

21. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Headache - ataxia - bulbar dysfunction

22. acalculus cholecystitis
Study showed no adverse effect; but they are contraindicated for PVD
Amoxicillin-clavulanate
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elderly and critically ill patients

23. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
S2-S4
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Subphrenic abscess or other abdominal abscesses; order US or CT

24. management of hip fracture
50%; tunneling between rectum or kin
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

25. common complication of inadequate mx of scaphoid fx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis
Nonunion and avascular necrosis; fx can block blood supply;

26. 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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

27. ct scan; cystic lesion in head of pancreas; next step
15-40%; self limiting;doesn't require tx
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

28. dorsiflexion and planter flexion
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization
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

29. swelling and tenderness in anterior part of knee
If patient ambulatory - surgery and pain control; if not nonop mx
Mammogram
Low anterior resection and radio; add chemo if node positive
Patellar tendon tear; difficulty in extension

30. What is the complications of undescended testis
Ispilateral hypoglossal nerve injury
Even after ochiopexy risk of ochiopexy higher then general population
Epi and chest compressio for prolong period of time; atropine is given after epi;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

31. stress 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
24-48 hours of supportive therapy followed by cholecystectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

32. when scaphoid fx patient needs to be referred to orthopedic
Study showed no adverse effect; but they are contraindicated for PVD
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Fx displace >1mm - nonunion during followup - osteonecrosis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

33. management of gunshot wound
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS

34. characteristics of ureteral stone?
Dumping syndrome; small and frequent meals; no simple sugar
If patient ambulatory - surgery and pain control; if not nonop mx
Elderly and critically ill patients
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

35. scrotal trauma
50%; tunneling between rectum or kin
Next best step surgery; not ultrasound
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
Check ET tube placement if correct needle decompresion

36. When do we see complications due to hypophosphatemia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS
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;
Dm neuropathy; stocking glove pattern

37. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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;
Progressive fibrosis of palmar fascia. etiololgy not known;

38. aspiration of breast cyst is bloody
Elderly and critically ill patients
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
4-6 weeks for noncontact sports and longer time for contact sports
Mammogram

39. What is terrible triad
Urethral stricture; pelvic of urethral trauma
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
15-40%; self limiting;doesn't require tx

40. What is hungry bone syndrome?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Twisting force with the foot fixed on the ground seen in football and basketball games;

41. differential of ultrasound finding of breast mass
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Next best step surgery; not ultrasound
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

42. What is hydrocele?
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Compression stocking - weight reduction - leg elevation

43. 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;
Pure motor stroke; limited neurological dysfunction
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

44. Tx of proximal non metastatic rectal ca
Saline and silicone
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Low anterior resection and radio; add chemo if node positive

45. Why varicocele more common in the left side
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

46. Why initial xrays are negative in scaphoid fx
S2-S4
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Displaced ORIF ; nondisplaced sling immobilization

47. complication displaced or communited distal radial fx
Elderly and critically ill patients
Carpal tunnel syndrom
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
Strok and traumatic brain injury

48. conservative Tx of varicose veins
Subphrenic abscess or other abdominal abscesses; order US or CT
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Compression stocking - weight reduction - leg elevation

49. How to differentiate communicative and non-communicative hydrocele
Ispilateral hypoglossal nerve injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
If patient ambulatory - surgery and pain control; if not nonop mx
Increased size during the day and valsalva means it is communicated with peritoneal cavity

50. When to do surgery in undesceneded testis?
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur