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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. first line of management of PVD
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Malignancy until proven otherwise
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

2. management of gunshot wound
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
10-12 months
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

3. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

4. contraindication of urethral catheterization
Tendons more likely
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Urethral stricture; pelvic of urethral trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

5. What is most common lung injury after blunt chest trauma?
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
4-6 weeks for noncontact sports and longer time for contact sports
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
When urethral catherization is unsuccessful

6. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Twisting force with the foot fixed on the ground seen in football and basketball games;
Klinefelter syndrome; 50 fold increase;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
15-40%; self limiting;doesn't require tx

7. Valgus and Varus tests
Dumping syndrome; small and frequent meals; no simple sugar
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Brardycardia - HTN - resp depression
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

8. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
When urethral catherization is unsuccessful
Mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

9. SOB - confusion - petechial rash after trauma - fracture
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

10. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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

11. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
24-48 hours of supportive therapy followed by cholecystectomy

12. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
50%; tunneling between rectum or kin
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

13. DD of acute scrotal pain
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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 tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

14. when patient with severe lung disease have C02 retention
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Meniscus injury; medial most common; pain/swelling; popping sensation
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

15. severe pain in leg after MVC
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Malignancy until proven otherwise
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

16. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Strok and traumatic brain injury
Tendons more likely
Even after ochiopexy risk of ochiopexy higher then general population
Subphrenic abscess or other abdominal abscesses; order US or CT

17. dorsiflexion and planter flexion
Progressive fibrosis of palmar fascia. etiololgy not known;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2

18. How to confirm achiles tendon rupture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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
Supraglottic edema; low threshold for intubation
Increased size during the day and valsalva means it is communicated with peritoneal cavity

19. How to evaluate painless testicular swelling suspicious for cancer
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

20. scrotal trauma
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
50%; tunneling between rectum or kin
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

21. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
15-40%; self limiting;doesn't require tx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Ispilateral hypoglossal nerve injury

22. diarrhoea 4-5 days after cholecystectomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports

23. transrectal prostate biopsy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Next best step surgery; not ultrasound

24. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Check ET tube placement if correct needle decompresion
Urethral stricture; pelvic of urethral trauma

25. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Pure motor stroke; limited neurological dysfunction
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;
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. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Klinefelter syndrome; 50 fold increase;

27. anal sphincter tone
Cystic scrotal fluid collection between parietal and visceral layers of testis
ACL injury
S2-S4
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

28. What is terrible triad
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Amoxicillin-clavulanate
Less than 5mm
MAT; medial meniscus injury; ACL and Tibial colateral ligament

29. swelling and tenderness in anterior part of knee
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Seminomas
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Patellar tendon tear; difficulty in extension

30. What is hungry bone syndrome?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

31. menisci injury
Next best step surgery; not ultrasound
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

32. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months
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

33. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Meniscus injury; medial most common; pain/swelling; popping sensation

34. managment of animal bite in hands
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
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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

35. mx of stress fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If any compressive symptoms eg. dysphagia

36. acalculus cholecystitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Meniscus injury; medial most common; pain/swelling; popping sensation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Elderly and critically ill patients

37. Complications of breast impant
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elderly and critically ill patients
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

38. several knee pain after being tackled in football game
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Seminomas

39. inhalation of hot air - steam - smoke in burn victim
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Supraglottic edema; low threshold for intubation
Mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

40. xray finding of stress fx after 3-4w
15-40%; self limiting;doesn't require tx
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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. when scaphoid fx patient needs to be referred to orthopedic
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Fx displace >1mm - nonunion during followup - osteonecrosis
Displaced ORIF ; nondisplaced sling immobilization
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

42. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

43. When to do surgery in undesceneded testis?
Elevated non seminomas
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

44. dumping syndrome after gastrectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Carpal tunnel syndrom
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sphincter sparing surgery (local resection) - abdomnio perineal resection

45. How to dx ACL tear?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
15-40%; self limiting;doesn't require tx
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

46. characteristics of ureteral stone?
Elderly and critically ill patients
If any compressive symptoms eg. dysphagia
Ispilateral hypoglossal nerve injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

47. When goiter needs surgery
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 any compressive symptoms eg. dysphagia
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;
Saline and silicone

48. mangement of localized lymphadenopathy
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

49. types of hip fracture
If any compressive symptoms eg. dysphagia
Headache - ataxia - bulbar dysfunction
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

50. most frequent complication of TURP
Retrograde ejaculation
Meniscus injury; medial most common; pain/swelling; popping sensation
Epi and chest compressio for prolong period of time; atropine is given after epi;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea