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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. Why right varicocele is more concerning?

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2. 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
Low anterior resection and radio; add chemo if node positive
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

3. aspiration of breast cyst is nonbloody
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ispilateral hypoglossal nerve injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

4. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Tendons more likely
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

5. varicose veins with ulcer - bleeding and thrombophlebitits
Subphrenic abscess or other abdominal abscesses; order US or CT
S2-S4
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

6. Why initial xrays are negative in scaphoid fx
Dumping syndrome; small and frequent meals; no simple sugar
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

7. differential of ultrasound finding of breast mass
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;
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
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

8. What is prehn sign?
Amoxicillin-clavulanate
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
Compression stocking - weight reduction - leg elevation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

9. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Retrograde ejaculation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Malignancy until proven otherwise

10. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
SAH due to post communicating artery aneurysm;
CRPS
Elderly and critically ill patients
Abd pain and tenderness; bloody diarrhoea or hematochezia

11. 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
When urethral catherization is unsuccessful
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Twisting force with the foot fixed on the ground seen in football and basketball games;

12. Dupuytren contracture
Less than 5mm
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Progressive fibrosis of palmar fascia. etiololgy not known;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

13. complication displaced or communited distal radial fx
Tendons more likely
Carpal tunnel syndrom
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

14. lacunar stroke
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fx displace >1mm - nonunion during followup - osteonecrosis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pure motor stroke; limited neurological dysfunction

15. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dm neuropathy; stocking glove pattern

16. first line of management of PVD
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
Nonunion and avascular necrosis; fx can block blood supply;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

17. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Next best step surgery; not ultrasound
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
L5 to S2

18. managment of animal bite in hands
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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;
10-12 months

19. How to manage obesity
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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;
Nonunion and avascular necrosis; fx can block blood supply;

20. perioral numbness after parathyroidectomy
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Low anterior resection and radio; add chemo if node positive

21. transrectal prostate biopsy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

22. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Next best step surgery; not ultrasound
50%; tunneling between rectum or kin
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

23. SAH due to posterior inferior cerebellar aneurysm
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If any compressive symptoms eg. dysphagia
Headache - ataxia - bulbar dysfunction

24. When patient can go back to sports after clavicle fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
4-6 weeks for noncontact sports and longer time for contact sports
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

25. acalculus cholecystitis
Malignancy until proven otherwise
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely
Elderly and critically ill patients

26. How varicocele causes testicular atrophy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elderly and critically ill patients
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

27. Tx of proximal non metastatic rectal ca
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Low anterior resection and radio; add chemo if node positive
Carpal tunnel syndrom
Cystic scrotal fluid collection between parietal and visceral layers of testis

28. severe pain in leg after MVC
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

29. What time frame required for bone remodeling
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Brardycardia - HTN - resp depression
Carpal tunnel syndrom
10-12 months

30. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Strok and traumatic brain injury
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
Elderly and critically ill patients

31. 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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Subphrenic abscess or other abdominal abscesses; order US or CT

32. acute colonic ischemia
Seminomas
Next best step surgery; not ultrasound
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2

33. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
ACL injury
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
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

34. How to confirm achiles tendon rupture
Check ET tube placement if correct needle decompresion
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
Saline and silicone
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

35. inhalation of hot air - steam - smoke in burn victim
24-48 hours of supportive therapy followed by cholecystectomy
Elevated non seminomas
Malignancy until proven otherwise
Supraglottic edema; low threshold for intubation

36. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dm neuropathy; stocking glove pattern
Epi and chest compressio for prolong period of time; atropine is given after epi;

37. mx of stress fx
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Even after ochiopexy risk of ochiopexy higher then general population
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

38. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
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
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
S2-S4

39. scrotal trauma
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
Next best step surgery; not ultrasound
Seminomas

40. most frequent complication of TURP
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Ampicillin sublactum - pipercillin - ceftriaxone and metro

41. tx distal rectal ca
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

42. What is terrible triad
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Epi and chest compressio for prolong period of time; atropine is given after epi;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

43. How to manage a patient with asystole
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check ET tube placement if correct needle decompresion
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. When do we see complications due to hypophosphatemia
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;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Low anterior resection and radio; add chemo if node positive

45. Incidence of AF in CABG patient

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46. When goiter needs surgery
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If any compressive symptoms eg. dysphagia
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

47. contraindication of urethral catheterization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
10-12 months
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Urethral stricture; pelvic of urethral trauma

48. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Nonunion and avascular necrosis; fx can block blood supply;
Carpal tunnel syndrom
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

49. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Epi and chest compressio for prolong period of time; atropine is given after epi;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

50. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea