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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 is terrible triad
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

2. What is hydrocele?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cystic scrotal fluid collection between parietal and visceral layers of 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;

3. What time frame required for bone remodeling
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
10-12 months

4. Indication for bariatric surgery in obese patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Low anterior resection and radio; add chemo if node positive
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;

5. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

6. most common complication of acute cholecystitis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

7. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
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

8. ipsilateral deviation of tongue upon protrusion
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Ispilateral hypoglossal nerve injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

9. clavicle fx
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization
When urethral catherization is unsuccessful
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

10. transrectal prostate biopsy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Meniscus injury; medial most common; pain/swelling; popping sensation
Check ET tube placement if correct needle decompresion

11. pregnant patient with asymptomatic gall stones
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
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
SAH due to post communicating artery aneurysm;

12. inhalation of hot air - steam - smoke in burn victim
Compression stocking - weight reduction - leg elevation
Supraglottic edema; low threshold for intubation
Unilateral vocal cord paralysis
Subphrenic abscess or other abdominal abscesses; order US or CT

13. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Twisting force with the foot fixed on the ground seen in football and basketball games;
ACL injury
Supraglottic edema; low threshold for intubation

14. Most common of sudden death due to steering wheel injury
Tendons more likely
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

15. 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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Malignancy until proven otherwise

16. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Less than 5mm
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Retrograde ejaculation

17. scrotal trauma
Meniscus injury; medial most common; pain/swelling; popping sensation
Next best step surgery; not ultrasound
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

18. diarrhoea after gastric bypass
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If any compressive symptoms eg. dysphagia
Dumping syndrome; small and frequent meals; no simple sugar

19. ct scan; cystic lesion in head of pancreas; next step
Malignancy until proven otherwise
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

20. How mcmurray manuver perform
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
Even after ochiopexy risk of ochiopexy higher then general population
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Amoxicillin-clavulanate

21. managment of animal bite in hands
Klinefelter syndrome; 50 fold increase;
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;
Nonunion and avascular necrosis; fx can block blood supply;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

22. What types of breast implants are available
Malignancy until proven otherwise
Saline and silicone
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
50%; tunneling between rectum or kin

23. dorsiflexion and planter flexion
Supraglottic edema; low threshold for intubation
L5 to S2
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Low anterior resection and radio; add chemo if node positive

24. What percent of anal abscess deveolop fisutula
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
50%; tunneling between rectum or kin
If patient ambulatory - surgery and pain control; if not nonop mx
15-40%; self limiting;doesn't require tx

25. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Urethral stricture; pelvic of urethral trauma
Malignancy until proven otherwise
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;

26. What is cushing's triad
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Tendons more likely
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

27. How to evaluate painless testicular swelling suspicious for cancer
50%; tunneling between rectum or kin
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Abd pain and tenderness; bloody diarrhoea or hematochezia

28. What is hungry bone syndrome?
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Amoxicillin-clavulanate
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

29. beta hcg and AFP
Elevated non seminomas
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dm neuropathy; stocking glove pattern
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

30. perioral numbness after parathyroidectomy
Malignancy until proven otherwise
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Even after ochiopexy risk of ochiopexy higher then general population

31. aspiration of breast cyst is nonbloody
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
SAH due to post communicating artery aneurysm;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

32. When to do surgery in undesceneded testis?
Compression stocking - weight reduction - leg elevation
Low anterior resection and radio; add chemo if node positive
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

33. management of nondisplaced scaphoid fx
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Even after ochiopexy risk of ochiopexy higher then general population
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

34. How to manage obesity
24-48 hours of supportive therapy followed by cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Meniscus injury; medial most common; pain/swelling; popping sensation
If patient ambulatory - surgery and pain control; if not nonop mx

35. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
CRPS
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

36. Can we use beta blocker for pvd?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Study showed no adverse effect; but they are contraindicated for PVD
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

37. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

38. Complications of breast impant
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

39. prostate enlarged - nontender - no nodularity - elevated PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
4-6 weeks for noncontact sports and longer time for contact sports

40. lacerated wound in palmer surface of hand. what structure is injured?
Displaced ORIF ; nondisplaced sling immobilization
Amoxicillin-clavulanate
Tendons more likely
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

41. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Displaced ORIF ; nondisplaced sling immobilization
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

42. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Study showed no adverse effect; but they are contraindicated for PVD
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

43. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Amoxicillin-clavulanate
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

44. diarrhoea 4-5 days after cholecystectomy
Low anterior resection and radio; add chemo if node positive
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

45. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Subphrenic abscess or other abdominal abscesses; order US or CT

46. suprapubic catheterization
When urethral catherization is unsuccessful
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Retrograde ejaculation
Strok and traumatic brain injury

47. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
When urethral catherization is unsuccessful
Strok and traumatic brain injury
Saline and silicone
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

48. 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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
SAH due to post communicating artery aneurysm;

49. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

50. popping sensation; rapid onset of knee effusion. athelet
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
ACL injury
When urethral catherization is unsuccessful
Cystic scrotal fluid collection between parietal and visceral layers of testis