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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. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Less than 5mm
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Compression stocking - weight reduction - leg elevation

2. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
4-6 weeks for noncontact sports and longer time for contact sports
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

3. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

4. clavicle fx
Subphrenic abscess or other abdominal abscesses; order US or CT
Displaced ORIF ; nondisplaced sling immobilization
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

5. How varicocele causes testicular atrophy
Saline and silicone
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Twisting force with the foot fixed on the ground seen in football and basketball games;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

6. sudden onset of postoperative hyperglycemia when patient on TPN
Retrograde ejaculation
Patellar tendon tear; difficulty in extension
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

7. menisci injury
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2
Twisting force with the foot fixed on the ground seen in football and basketball games;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

8. What is prehn sign?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Retrograde ejaculation
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

9. How mcmurray manuver perform
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Saline and silicone
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

10. Valgus and Varus tests
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar

11. pregnant patient with asymptomatic gall stones
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

12. indication of ursodeoxycholic acid
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
Nonunion and avascular necrosis; fx can block blood supply;
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
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

13. When patient can go back to sports after clavicle fx
Dm neuropathy; stocking glove pattern
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Nonunion and avascular necrosis; fx can block blood supply;
4-6 weeks for noncontact sports and longer time for contact sports

14. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Seminomas
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Progressive fibrosis of palmar fascia. etiololgy not known;

15. mx of stress fx
Saline and silicone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

16. acalculus cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elderly and critically ill patients
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

17. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;
Brardycardia - HTN - resp depression

18. How to differentiate communicative and non-communicative hydrocele
ACL 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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

19. Why varicocele more common in the left side
Meniscus injury; medial most common; pain/swelling; popping sensation
Cystic scrotal fluid collection between parietal and visceral layers of testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

20. When to stop raloxifene before surgery
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Seminomas
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

21. What are the common injuries from lightning?
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Low anterior resection and radio; add chemo if node positive

22. lacunar stroke
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
S2-S4
Pure motor stroke; limited neurological dysfunction

23. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Epi and chest compressio for prolong period of time; atropine is given after epi;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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;

24. complication displaced or communited distal radial fx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Carpal tunnel syndrom

25. 3 mo with groin bulge; bulge appears when child cries
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

26. prostate enlarged - nontender - no nodularity - elevated PSA
Displaced ORIF ; nondisplaced sling immobilization
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
24-48 hours of supportive therapy followed by cholecystectomy

27. varicocele
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

28. Why initial xrays are negative in scaphoid fx
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

29. how ABI help dx of PVD
Sphincter sparing surgery (local resection) - abdomnio perineal resection
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
ACL injury
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

30. Can we use beta blocker for pvd?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Study showed no adverse effect; but they are contraindicated for PVD
Nonunion and avascular necrosis; fx can block blood supply;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

31. when scaphoid fx patient needs to be referred to orthopedic
24-48 hours of supportive therapy followed by cholecystectomy
Low anterior resection and radio; add chemo if node positive
Epi and chest compressio for prolong period of time; atropine is given after epi;
Fx displace >1mm - nonunion during followup - osteonecrosis

32. managment of animal bite in hands
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Brardycardia - HTN - resp depression
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

33. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Nonunion and avascular necrosis; fx can block blood supply;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

34. beta hcg and AFP
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elevated non seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

35. What is the complications of undescended testis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Carpal tunnel syndrom
Even after ochiopexy risk of ochiopexy higher then general population
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

36. tx distal rectal ca
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4-6 weeks for noncontact sports and longer time for contact sports
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

37. diarrhoea after gastric bypass
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
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

38. most frequent complication of TURP
Epi and chest compressio for prolong period of time; atropine is given after epi;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports
Retrograde ejaculation

39. most common complication of acute cholecystitis
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 phosphate levels fall below 1.0; 30% of patient on TPN has this prob; patient develop respiratory weakness - hemolysis - impaired oxygen release from Hb;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Check ET tube placement if correct needle decompresion

40. 27 yo with scrotal mass; warm tender testes feel like bag of worms
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Elderly and critically ill patients
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

41. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

42. What is cushing's triad
Brardycardia - HTN - resp depression
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Unilateral vocal cord paralysis

43. scrotal trauma
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
If patient ambulatory - surgery and pain control; if not nonop mx
Next best step surgery; not ultrasound

44. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Strok and traumatic brain injury

45. anal sphincter tone
S2-S4
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Twisting force with the foot fixed on the ground seen in football and basketball games;

46. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Headache - ataxia - bulbar dysfunction
Fx displace >1mm - nonunion during followup - osteonecrosis

47. What is the strongest risk factor for male breast cancer
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Klinefelter syndrome; 50 fold increase;
Carpal tunnel syndrom

48. characteristics of ureteral stone?
Meniscus injury; medial most common; pain/swelling; popping sensation
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

49. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Urethral stricture; pelvic of urethral trauma
Seminomas

50. When to do surgery in undesceneded testis?
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;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid