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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. swelling and tenderness in anterior part of knee
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Patellar tendon tear; difficulty in extension
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Twisting force with the foot fixed on the ground seen in football and basketball games;

2. Why ruq calcificaion is concerning
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cystic scrotal fluid collection between parietal and visceral layers of testis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

3. What percent of anal abscess deveolop fisutula
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
Supraglottic edema; low threshold for intubation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
50%; tunneling between rectum or kin

4. scrotal trauma
Tendons more likely
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Next best step surgery; not ultrasound

5. transrectal prostate biopsy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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;
Seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

6. painless testicular mass in young male
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Seminomas
Meniscus injury; medial most common; pain/swelling; popping sensation
Malignancy until proven otherwise

7. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
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
Seminomas
Mammogram

8. management of gunshot wound
Mammogram
Seminomas
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 ET tube placement if correct needle decompresion

9. Why varicocele more common in the left side
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Study showed no adverse effect; but they are contraindicated for PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

10. how ABI help dx of PVD
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

11. most common fx when falling on outsretched hand
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

12. Incidence of AF in CABG patient

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13. How to manage obesity
CRPS
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check ET tube placement if correct needle decompresion
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

14. recurrent laryngeal nerve injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Unilateral vocal cord paralysis
24-48 hours of supportive therapy followed by cholecystectomy
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

15. What is prehn sign?
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

16. severe pain in leg after MVC
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Meniscus injury; medial most common; pain/swelling; popping sensation

17. 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;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

18. most frequent complication of TURP
Amoxicillin-clavulanate
Klinefelter syndrome; 50 fold increase;
Retrograde ejaculation
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

19. varicocele
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Meniscus injury; medial most common; pain/swelling; popping sensation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

20. Why initial xrays are negative in scaphoid fx
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Malignancy until proven otherwise
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

21. beta HCG
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Seminomas
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Nonunion and avascular necrosis; fx can block blood supply;

22. mx of stress fx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

23. Tx of proximal non metastatic rectal ca
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Strok and traumatic brain injury
Low anterior resection and radio; add chemo if node positive
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

24. suprapubic catheterization
When urethral catherization is unsuccessful
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
4-6 weeks for noncontact sports and longer time for contact sports
Next best step surgery; not ultrasound

25. popping sensation; rapid onset of knee effusion. athelet
Meniscus injury; medial most common; pain/swelling; popping sensation
SAH due to post communicating artery aneurysm;
ACL injury
Urethral stricture; pelvic of urethral trauma

26. tx distal rectal ca
Malignancy until proven otherwise
Saline and silicone
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Sphincter sparing surgery (local resection) - abdomnio perineal resection

27. How to evaluate painless testicular swelling suspicious for cancer
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Nonunion and avascular necrosis; fx can block blood supply;

28. How to confirm achiles tendon rupture
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
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
L5 to S2
Patellar tendon tear; difficulty in extension

29. Why right varicocele is more concerning?

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30. sudden onset of postoperative hyperglycemia when patient on TPN
Fx displace >1mm - nonunion during followup - osteonecrosis
15-40%; self limiting;doesn't require tx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Ispilateral hypoglossal nerve injury

31. Valgus and Varus tests
Amoxicillin-clavulanate
4-6 weeks for noncontact sports and longer time for contact sports
15-40%; self limiting;doesn't require tx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

32. 27 yo with scrotal mass; warm tender testes feel like bag of worms
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

33. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Patellar tendon tear; difficulty in extension

34. ipsilateral deviation of tongue upon protrusion
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Ispilateral hypoglossal nerve injury

35. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dm neuropathy; stocking glove pattern
Retrograde ejaculation
SAH due to post communicating artery aneurysm;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

36. first line of management of PVD
Dumping syndrome; small and frequent meals; no simple sugar
Seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

37. Can we use beta blocker for pvd?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
ACL injury
Study showed no adverse effect; but they are contraindicated for PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

38. when patient with severe lung disease have C02 retention
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
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

39. types of hip fracture
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
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

40. first step for evaluation of testicular swelling
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

41. xray finding of stress fx after 3-4w
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;
Elevated non seminomas
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

42. What is hydrocele?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
15-40%; self limiting;doesn't require tx
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

43. How to manage a patient with asystole
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
24-48 hours of supportive therapy followed by cholecystectomy

44. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
ACL injury
Brardycardia - HTN - resp depression
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

45. indication of ursodeoxycholic acid
Seminomas
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
Pure motor stroke; limited neurological dysfunction
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

46. differential of ultrasound finding of breast mass
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
ACL injury
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

47. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Supraglottic edema; low threshold for intubation
Meniscus injury; medial most common; pain/swelling; popping sensation

48. surgery for acute cholecystities
Compression stocking - weight reduction - leg elevation
Amoxicillin-clavulanate
24-48 hours of supportive therapy followed by cholecystectomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

49. When to do surgery in undesceneded testis?
Unilateral vocal cord paralysis
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

50. mangement of localized lymphadenopathy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Less than 5mm