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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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Urethral stricture; pelvic of urethral trauma
Displaced ORIF ; nondisplaced sling immobilization

2. how ABI help dx of PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Amoxicillin-clavulanate
Retrograde ejaculation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

3. When goiter needs surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If any compressive symptoms eg. dysphagia
Nonunion and avascular necrosis; fx can block blood supply;
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

4. most frequent complication of TURP
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Pure motor stroke; limited neurological dysfunction
Retrograde ejaculation
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;

5. Tx of proximal non metastatic rectal ca
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

6. varicocele
Progressive fibrosis of palmar fascia. etiololgy not known;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
ACL injury
Elderly and critically ill patients

7. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation

8. SAH due to posterior inferior cerebellar aneurysm
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Headache - ataxia - bulbar dysfunction

9. perioral numbness after parathyroidectomy
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Displaced ORIF ; nondisplaced sling immobilization

10. Most common of sudden death due to steering wheel injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
S2-S4

11. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
4-6 weeks for noncontact sports and longer time for contact sports
Subphrenic abscess or other abdominal abscesses; order US or CT
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

12. mx of stress fx
Compression stocking - weight reduction - leg elevation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

13. 3 mo with groin bulge; bulge appears when child cries
24-48 hours of supportive therapy followed by cholecystectomy
CRPS
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

14. popping sensation; rapid onset of knee effusion. athelet
ACL injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Next best step surgery; not ultrasound
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

15. management of stone 8-10mm
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

16. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS

17. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
24-48 hours of supportive therapy followed by cholecystectomy
Elevated non seminomas
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;

18. SOB - confusion - petechial rash after trauma - fracture
Supraglottic edema; low threshold for intubation
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
L5 to S2

19. painless testicular mass in young male
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Displaced ORIF ; nondisplaced sling immobilization
Malignancy until proven otherwise

20. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
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;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

21. What is the complications of undescended testis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Even after ochiopexy risk of ochiopexy higher then general population
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
Less than 5mm

22. what size of ureteral stone for non op mx
Mammogram
Next best step surgery; not ultrasound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Less than 5mm

23. dorsiflexion and planter flexion
Elevated non seminomas
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
L5 to S2

24. How to confirm dx of compartment syndrom
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Compression stocking - weight reduction - leg elevation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Strok and traumatic brain injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

26. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If any compressive symptoms eg. dysphagia
Ispilateral hypoglossal nerve injury

27. stress fx
Dm neuropathy; stocking glove pattern
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

28. common complication of inadequate mx of scaphoid fx
Elevated non seminomas
Ispilateral hypoglossal nerve injury
Nonunion and avascular necrosis; fx can block blood supply;
Strok and traumatic brain injury

29. Indication for bariatric surgery in obese patients
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Retrograde ejaculation
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;

30. What are the common injuries from lightning?
S2-S4
Ispilateral hypoglossal nerve injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Klinefelter syndrome; 50 fold increase;

31. How to manage obesity
L5 to S2
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Tendons more likely
Saline and silicone

32. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Carpal tunnel syndrom

33. Can we use beta blocker for pvd?
ACL injury
Study showed no adverse effect; but they are contraindicated for PVD
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pure motor stroke; limited neurological dysfunction

34. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

35. Complications of breast impant
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Twisting force with the foot fixed on the ground seen in football and basketball games;
Urethral stricture; pelvic of urethral trauma

36. characteristics of ureteral stone?
Carpal tunnel syndrom
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Twisting force with the foot fixed on the ground seen in football and basketball games;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

37. How varicocele causes testicular atrophy
Nonunion and avascular necrosis; fx can block blood supply;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Fx displace >1mm - nonunion during followup - osteonecrosis
CRPS

38. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

39. antibiotics of acute cholecystitis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Meniscus injury; medial most common; pain/swelling; popping sensation
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

40. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pure motor stroke; limited neurological dysfunction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If patient ambulatory - surgery and pain control; if not nonop mx

41. How to perform lachman test
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
50%; tunneling between rectum or kin
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
SAH due to post communicating artery aneurysm;

42. Why varicocele more common in the left side
Mammogram
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dm neuropathy; stocking glove pattern

43. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Amoxicillin-clavulanate
Abd pain and tenderness; bloody diarrhoea or hematochezia
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Meniscus injury; medial most common; pain/swelling; popping sensation

44. anal sphincter tone
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;
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
S2-S4

45. lacunar stroke
If any compressive symptoms eg. dysphagia
Pure motor stroke; limited neurological dysfunction
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

46. pregnant patient with asymptomatic gall stones
15-40%; self limiting;doesn't require tx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
L5 to S2

47. beta hcg and AFP
Dm neuropathy; stocking glove pattern
Elevated non seminomas
Meniscus injury; medial most common; pain/swelling; popping sensation
Supraglottic edema; low threshold for intubation

48. Dupuytren contracture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Progressive fibrosis of palmar fascia. etiololgy not known;

49. prostate enlarged - nontender - no nodularity - elevated PSA
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
ACL injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Malignancy until proven otherwise

50. first line of management of PVD
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Headache - ataxia - bulbar dysfunction
MAT; medial meniscus injury; ACL and Tibial colateral ligament