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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. conservative Tx of varicose veins
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Compression stocking - weight reduction - leg elevation

2. management of hip fracture
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 patient ambulatory - surgery and pain control; if not nonop mx
Dumping syndrome; small and frequent meals; no simple sugar

3. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Headache - ataxia - bulbar dysfunction
Dm neuropathy; stocking glove pattern

4. Dupuytren contracture
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Progressive fibrosis of palmar fascia. etiololgy not known;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Headache - ataxia - bulbar dysfunction

5. What is cushing's triad
Abd pain and tenderness; bloody diarrhoea or hematochezia
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Brardycardia - HTN - resp depression

6. inhalation of hot air - steam - smoke in burn victim
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

7. 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
Progressive fibrosis of palmar fascia. etiololgy not known;
Mammogram
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

8. How to dx ACL tear?
Saline and silicone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

9. When to do surgery in undesceneded testis?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

10. anal sphincter tone
Elevated non seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis
S2-S4
Meniscus injury; medial most common; pain/swelling; popping sensation

11. How to confirm achiles tendon rupture
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
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
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
Less than 5mm

12. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

13. how hyperventilation lowers ICP
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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 lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

14. diarrhoea after gastric bypass
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Dumping syndrome; small and frequent meals; no simple sugar
Elevated non seminomas

15. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Next best step surgery; not ultrasound
Study showed no adverse effect; but they are contraindicated for PVD

16. acute colonic ischemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
ACL injury
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

17. complication displaced or communited distal radial fx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Carpal tunnel syndrom
If patient ambulatory - surgery and pain control; if not nonop mx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

18. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

19. most frequent complication of TURP
Tendons more likely
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
When urethral catherization is unsuccessful
Retrograde ejaculation

20. ipsilateral deviation of tongue upon protrusion
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
Ispilateral hypoglossal nerve injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

21. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elevated non seminomas
Next best step surgery; not ultrasound
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

22. How varicocele causes testicular atrophy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sphincter sparing surgery (local resection) - abdomnio perineal resection

23. When patient can go back to sports after clavicle fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
4-6 weeks for noncontact sports and longer time for contact sports
Meniscus injury; medial most common; pain/swelling; popping sensation
Abd pain and tenderness; bloody diarrhoea or hematochezia

24. What is prehn sign?
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

25. How to manage obesity
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

26. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

27. diarrhoea 4-5 days after cholecystectomy
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

28. What time frame required for bone remodeling
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
10-12 months
S2-S4
Increased size during the day and valsalva means it is communicated with peritoneal cavity

29. How to manage a patient with asystole
Check ET tube placement if correct needle decompresion
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Epi and chest compressio for prolong period of time; atropine is given after epi;

30. perioral numbness after parathyroidectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Brardycardia - HTN - resp depression
Carpal tunnel syndrom
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

31. several knee pain after being tackled in football game
Ispilateral hypoglossal nerve injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

32. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elderly and critically ill patients
Next best step surgery; not ultrasound
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

33. transrectal prostate biopsy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Even after ochiopexy risk of ochiopexy higher then general population

34. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dumping syndrome; small and frequent meals; no simple sugar

35. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Next best step surgery; not ultrasound
Supraglottic edema; low threshold for intubation

36. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Subphrenic abscess or other abdominal abscesses; order US or CT
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevated non seminomas

37. acalculus cholecystitis
ACL injury
Amoxicillin-clavulanate
Elderly and critically ill patients
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

38. How to perform lachman test
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Twisting force with the foot fixed on the ground seen in football and basketball games;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased size during the day and valsalva means it is communicated with peritoneal cavity

39. midline neck swelling moves with protrusion of tongue
Elevated non seminomas
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
Elderly and critically ill patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

40. What is terrible triad
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
10-12 months
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

41. How to differentiate communicative and non-communicative hydrocele
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;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Check ET tube placement if correct needle decompresion
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

42. prostate enlarged - nontender - no nodularity - elevated PSA
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

43. What types of breast implants are available
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
Saline and silicone
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Next best step surgery; not ultrasound

44. suprapubic catheterization
10-12 months
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
When urethral catherization is unsuccessful

45. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Pure motor stroke; limited neurological dysfunction

46. How to differentiate ACL and meniscus 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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Low anterior resection and radio; add chemo if node positive
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

47. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

48. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Malignancy until proven otherwise
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check ET tube placement if correct needle decompresion

49. 27 yo with scrotal mass; warm tender testes feel like bag of worms
10-12 months
Carpal tunnel syndrom
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
50%; tunneling between rectum or kin

50. contraindication of urethral catheterization
4-6 weeks for noncontact sports and longer time for contact sports
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Urethral stricture; pelvic of urethral trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp