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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 hydrocele?
CRPS
Dm neuropathy; stocking glove pattern
Amoxicillin-clavulanate
Cystic scrotal fluid collection between parietal and visceral layers of testis

2. Complications of breast impant
S2-S4
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If any compressive symptoms eg. dysphagia

3. first line of management of PVD
Low anterior resection and radio; add chemo if node positive
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;

4. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
ACL injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

5. What is terrible triad
ACL 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
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

6. transrectal prostate biopsy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

7. How to dx ACL tear?
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
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 any compressive symptoms eg. dysphagia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

8. What is the strongest risk factor for male breast cancer
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pure motor stroke; limited neurological dysfunction
Klinefelter syndrome; 50 fold increase;
When urethral catherization is unsuccessful

9. beta HCG
Seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;

10. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Malignancy until proven otherwise
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

11. When to do surgery in undesceneded testis?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
50%; tunneling between rectum or kin
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

12. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
24-48 hours of supportive therapy followed by cholecystectomy

13. what size of ureteral stone for non op mx
Klinefelter syndrome; 50 fold increase;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Less than 5mm

14. characteristics of ureteral stone?
50%; tunneling between rectum or kin
Klinefelter syndrome; 50 fold increase;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

15. When to stop raloxifene before surgery
Carpal tunnel syndrom
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

16. management of stone 8-10mm
Ispilateral hypoglossal nerve injury
Even after ochiopexy risk of ochiopexy higher then general population
Headache - ataxia - bulbar dysfunction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

17. When patient can go back to sports after clavicle fx
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
4-6 weeks for noncontact sports and longer time for contact sports
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

18. common complication of inadequate mx of scaphoid fx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Nonunion and avascular necrosis; fx can block blood supply;

19. mx of stress fx
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
L5 to S2

20. How to evaluate painless testicular swelling suspicious for cancer
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.
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

21. aspiration of breast cyst is nonbloody
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

22. What are the common injuries from lightning?
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
Elevated non seminomas
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Fx displace >1mm - nonunion during followup - osteonecrosis

23. first step for evaluation of testicular swelling
Sphincter sparing surgery (local resection) - abdomnio perineal resection
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

24. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
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
Saline and silicone
ACL injury

25. ct scan; cystic lesion in head of pancreas; next step
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

26. dorsiflexion and planter flexion
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
L5 to S2
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

27. What time frame required for bone remodeling
10-12 months
Study showed no adverse effect; but they are contraindicated for PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation

28. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Pure motor stroke; limited neurological dysfunction
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

29. several knee pain after being tackled in football game
If patient ambulatory - surgery and pain control; if not nonop mx
Brardycardia - HTN - resp depression
SAH due to post communicating artery aneurysm;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

30. 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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check ET tube placement if correct needle decompresion

31. Tx of proximal non metastatic rectal ca
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
Low anterior resection and radio; add chemo if node positive
24-48 hours of supportive therapy followed by cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. management of hip fracture
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

33. when patient with severe lung disease have C02 retention
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
Mammogram
Elderly and critically ill patients
Dumping syndrome; small and frequent meals; no simple sugar

34. How to differentiate communicative and non-communicative hydrocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
CRPS
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

35. management of gunshot wound
Increased size during the day and valsalva means it is communicated with peritoneal cavity
SAH due to post communicating artery aneurysm;
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
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

36. popping sensation; rapid onset of knee effusion. athelet
Supraglottic edema; low threshold for intubation
Tendons more likely
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
ACL injury

37. midline neck swelling moves with protrusion of tongue
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
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

38. acalculus cholecystitis
Elderly and critically ill patients
Pure motor stroke; limited neurological dysfunction
CRPS
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

39. Most common of sudden death due to steering wheel injury
SAH due to post communicating artery aneurysm;
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;
Elderly and critically ill patients
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

40. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;
Compression stocking - weight reduction - leg elevation
Next best step surgery; not ultrasound

41. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Klinefelter syndrome; 50 fold increase;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

42. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
24-48 hours of supportive therapy followed by cholecystectomy
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

43. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Urethral stricture; pelvic of urethral trauma
Elevated non seminomas

44. What is cushing's triad
Low anterior resection and radio; add chemo if node positive
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Brardycardia - HTN - resp depression

45. most common complication of acute cholecystitis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Dumping syndrome; small and frequent meals; no simple sugar
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

46. Indication for bariatric surgery in obese patients
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;
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

47. Incidence of AF in CABG patient

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48. diarrhoea after gastric bypass
Even after ochiopexy risk of ochiopexy higher then general population
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dumping syndrome; small and frequent meals; no simple sugar
If any compressive symptoms eg. dysphagia

49. Valgus and Varus tests
SAH due to post communicating artery aneurysm;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months
Seminomas

50. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Progressive fibrosis of palmar fascia. etiololgy not known;