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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. beta hcg and AFP
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Amoxicillin-clavulanate
Elevated non seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

2. scrotal trauma
50%; tunneling between rectum or kin
Klinefelter syndrome; 50 fold increase;
Next best step surgery; not ultrasound
Dm neuropathy; stocking glove pattern

3. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Patellar tendon tear; difficulty in extension
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

4. antibiotics of acute cholecystitis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Ampicillin sublactum - pipercillin - ceftriaxone and metro

5. Why initial xrays are negative in scaphoid fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Retrograde ejaculation
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

6. What time frame required for bone remodeling
Brardycardia - HTN - resp depression
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
10-12 months

7. What is the strongest risk factor for male breast cancer
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Carpal tunnel syndrom
Klinefelter syndrome; 50 fold increase;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

8. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Next best step surgery; not ultrasound
Tendons more likely
Mammogram

9. ct scan; cystic lesion in head of pancreas; next step
When urethral catherization is unsuccessful
Elevated non seminomas
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

10. management of nondisplaced scaphoid fx
Dumping syndrome; small and frequent meals; no simple sugar
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

11. When to stop raloxifene before surgery
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Strok and traumatic brain injury

12. tx distal rectal ca
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

13. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm

14. How to confirm achiles tendon rupture
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
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

15. Why right varicocele is more concerning?

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16. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Less than 5mm
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;
Supraglottic edema; low threshold for intubation

17. What is most common lung injury after blunt chest trauma?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

18. mangement of localized lymphadenopathy
Even after ochiopexy risk of ochiopexy higher then general population
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

19. How to evaluate painless testicular swelling suspicious for cancer
Brardycardia - HTN - resp depression
Pure motor stroke; limited neurological dysfunction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Headache - ataxia - bulbar dysfunction

20. what size of ureteral stone for non op mx
Tendons more likely
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
Less than 5mm
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

21. managment of animal bite in hands
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;
Patellar tendon tear; difficulty in extension
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Sphincter sparing surgery (local resection) - abdomnio perineal resection

22. Can we use beta blocker for pvd?
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Study showed no adverse effect; but they are contraindicated for PVD

23. first line of management of PVD
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
L5 to S2
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

24. transrectal prostate biopsy
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
Malignancy until proven otherwise
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

25. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Dumping syndrome; small and frequent meals; no simple sugar
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
Compression stocking - weight reduction - leg elevation

26. suprapubic catheterization
Displaced ORIF ; nondisplaced sling immobilization
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
When urethral catherization is unsuccessful
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

27. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If any compressive symptoms eg. dysphagia

28. midline neck swelling moves with protrusion of tongue
Compression stocking - weight reduction - leg elevation
Cystic scrotal fluid collection between parietal and visceral layers of testis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
When urethral catherization is unsuccessful

29. What percent of anal abscess deveolop fisutula
Supraglottic edema; low threshold for intubation
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
50%; tunneling between rectum or kin
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

30. first step for evaluation of testicular swelling
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. acalculus cholecystitis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Elderly and critically ill patients
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Study showed no adverse effect; but they are contraindicated for PVD

32. types of hip fracture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

33. lacerated wound in palmer surface of hand. what structure is injured?
Twisting force with the foot fixed on the ground seen in football and basketball games;
Subphrenic abscess or other abdominal abscesses; order US or CT
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Tendons more likely

34. When goiter needs surgery
Progressive fibrosis of palmar fascia. etiololgy not known;
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
If any compressive symptoms eg. dysphagia

35. What is prehn sign?
Klinefelter syndrome; 50 fold increase;
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
4-6 weeks for noncontact sports and longer time for contact sports
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

36. complications of TPN
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

37. 3 mo with groin bulge; bulge appears when child cries
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

38. What is hydrocele?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Subphrenic abscess or other abdominal abscesses; order US or CT

39. most frequent complication of TURP
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Ispilateral hypoglossal nerve injury
Study showed no adverse effect; but they are contraindicated for PVD
Retrograde ejaculation

40. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Subphrenic abscess or other abdominal abscesses; order US or CT

41. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Twisting force with the foot fixed on the ground seen in football and basketball games;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

42. clavicle fx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Displaced ORIF ; nondisplaced sling immobilization

43. cremasteric reflex
Urethral stricture; pelvic of urethral trauma
Elderly and critically ill patients
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

44. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
Meniscus injury; medial most common; pain/swelling; popping sensation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Urethral stricture; pelvic of urethral trauma

45. severe pain in leg after MVC
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

46. Patient underwent CABG; postoperatively drowsy. most likely cause?
Malignancy until proven otherwise
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
Fx displace >1mm - nonunion during followup - osteonecrosis
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

47. differential of ultrasound finding of breast mass
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
Less than 5mm
Urethral stricture; pelvic of urethral trauma
Increased size during the day and valsalva means it is communicated with peritoneal cavity

48. Dupuytren contracture
Klinefelter syndrome; 50 fold increase;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Progressive fibrosis of palmar fascia. etiololgy not known;
Carpal tunnel syndrom

49. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If any compressive symptoms eg. dysphagia
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

50. varicocele
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position