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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. What types of breast implants are available
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
Saline and silicone
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

2. characteristics of ureteral stone?
Malignancy until proven otherwise
Epi and chest compressio for prolong period of time; atropine is given after epi;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

3. contraindication of urethral catheterization
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Urethral stricture; pelvic of urethral trauma
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

4. when scaphoid fx patient needs to be referred to orthopedic
Fx displace >1mm - nonunion during followup - osteonecrosis
L5 to S2
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Check ET tube placement if correct needle decompresion

5. What is hungry bone syndrome?
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Low anterior resection and radio; add chemo if node positive

6. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

7. xray finding of stress fx after 3-4w
Nonunion and avascular necrosis; fx can block blood supply;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
15-40%; self limiting;doesn't require tx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

8. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
SAH due to post communicating artery aneurysm;
Subphrenic abscess or other abdominal abscesses; order US or CT

9. severe pain in leg after MVC
4-6 weeks for noncontact sports and longer time for contact sports
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

10. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

11. 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
Pure motor stroke; limited neurological dysfunction
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

12. management of hip fracture
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If patient ambulatory - surgery and pain control; if not nonop mx
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

13. sudden onset of postoperative hyperglycemia when patient on TPN
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

14. Indication for bariatric surgery in obese patients
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
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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Supraglottic edema; low threshold for intubation

15. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Epi and chest compressio for prolong period of time; atropine is given after epi;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dumping syndrome; small and frequent meals; no simple sugar

16. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
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
10-12 months
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

17. recurrent laryngeal nerve injury
Pure motor stroke; limited neurological dysfunction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Unilateral vocal cord paralysis

18. dorsiflexion and planter flexion
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
L5 to S2
Amoxicillin-clavulanate
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

19. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Twisting force with the foot fixed on the ground seen in football and basketball games;

20. What time frame required for bone remodeling
Progressive fibrosis of palmar fascia. etiololgy not known;
If any compressive symptoms eg. dysphagia
10-12 months
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

21. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Nonunion and avascular necrosis; fx can block blood supply;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
50%; tunneling between rectum or kin

22. painless testicular mass in young male
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Malignancy until proven otherwise
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

23. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

24. suprapubic catheterization
Cystic scrotal fluid collection between parietal and visceral layers of testis
When urethral catherization is unsuccessful
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Progressive fibrosis of palmar fascia. etiololgy not known;

25. varicocele
Displaced ORIF ; nondisplaced sling immobilization
SAH due to post communicating artery aneurysm;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

26. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

27. aspiration of breast cyst is nonbloody
Progressive fibrosis of palmar fascia. etiololgy not known;
Next best step surgery; not ultrasound
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

28. management of nondisplaced scaphoid fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

29. types of hip fracture
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

30. ipsilateral deviation of tongue upon protrusion
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
CRPS
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ispilateral hypoglossal nerve injury

31. 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;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

32. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
SAH due to post communicating artery aneurysm;
Next best step surgery; not ultrasound

33. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Mammogram
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

34. Tx of proximal non metastatic rectal ca
Amoxicillin-clavulanate
Progressive fibrosis of palmar fascia. etiololgy not known;
Urethral stricture; pelvic of urethral trauma
Low anterior resection and radio; add chemo if node positive

35. transrectal prostate biopsy
Klinefelter syndrome; 50 fold increase;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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

36. What is most common lung injury after blunt chest trauma?
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elderly and critically ill patients
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

38. popping sensation; rapid onset of knee effusion. athelet
ACL injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

39. What is the complications of undescended testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Even after ochiopexy risk of ochiopexy higher then general population
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

40. inhalation of hot air - steam - smoke in burn victim
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Supraglottic edema; low threshold for intubation
Fx displace >1mm - nonunion during followup - osteonecrosis
Dm neuropathy; stocking glove pattern

41. What is terrible triad
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Unilateral vocal cord paralysis

42. How mcmurray manuver perform
Ispilateral hypoglossal nerve injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

43. Why initial xrays are negative in scaphoid fx
Elevated non seminomas
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

44. Tx of pulmonary contusion
Saline and silicone
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
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

45. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

46. dumping syndrome after gastrectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

47. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ampicillin sublactum - pipercillin - ceftriaxone and metro

48. scrotal trauma
Elderly and critically ill patients
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

49. mangement of localized lymphadenopathy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dm neuropathy; stocking glove pattern
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Less than 5mm

50. Patient underwent CABG; postoperatively drowsy. most likely cause?
Check ET tube placement if correct needle decompresion
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
ACL injury
Carpal tunnel syndrom