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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. painless testicular mass in young male
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Malignancy until proven otherwise

2. What is hydrocele?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

3. popping sensation; rapid onset of knee effusion. athelet
Strok and traumatic brain injury
ACL injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

4. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Tendons more likely
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Next best step surgery; not ultrasound

5. prostate enlarged - nontender - no nodularity - elevated PSA
Nonunion and avascular necrosis; fx can block blood supply;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ACL injury
Cystic scrotal fluid collection between parietal and visceral layers of testis

6. When do we see complications due to hypophosphatemia
15-40%; self limiting;doesn't require tx
Meniscus injury; medial most common; pain/swelling; popping sensation
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

7. What is terrible triad
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Cystic scrotal fluid collection between parietal and visceral layers of testis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Ispilateral hypoglossal nerve injury

8. antibiotics of acute cholecystitis
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
L5 to S2

9. mx of stress fx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

10. beta hcg and AFP
Elevated non seminomas
CRPS
10-12 months
4-6 weeks for noncontact sports and longer time for contact sports

11. suprapubic catheterization
When urethral catherization is unsuccessful
SAH due to post communicating artery aneurysm;
Retrograde ejaculation
S2-S4

12. management of hip fracture
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
S2-S4
If patient ambulatory - surgery and pain control; if not nonop mx
Ispilateral hypoglossal nerve injury

13. aspiration of breast cyst is bloody
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Mammogram
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population

14. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Supraglottic edema; low threshold for intubation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

15. 3 mo with groin bulge; bulge appears when child cries
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Less than 5mm
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

16. perioral numbness after parathyroidectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

17. managment of animal bite in hands
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
If patient ambulatory - surgery and pain control; if not nonop mx
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
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;

18. surgery for acute cholecystities
50%; tunneling between rectum or kin
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
24-48 hours of supportive therapy followed by cholecystectomy

19. lacunar stroke
Amoxicillin-clavulanate
Next best step surgery; not ultrasound
Patellar tendon tear; difficulty in extension
Pure motor stroke; limited neurological dysfunction

20. 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
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

21. mangement of localized lymphadenopathy
Retrograde ejaculation
Next best step surgery; not ultrasound
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

22. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
4-6 weeks for noncontact sports and longer time for contact sports
Ispilateral hypoglossal nerve injury
Headache - ataxia - bulbar dysfunction

23. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
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
CRPS
If patient ambulatory - surgery and pain control; if not nonop mx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

24. Can we use beta blocker for pvd?
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Study showed no adverse effect; but they are contraindicated for PVD
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Saline and silicone

25. when patient with severe lung disease have C02 retention
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
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
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
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

26. lacerated wound in palmer surface of hand. what structure is injured?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Tendons more likely

27. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Meniscus injury; medial most common; pain/swelling; popping sensation

28. how ABI help dx of PVD
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Klinefelter syndrome; 50 fold increase;

29. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT
Urethral stricture; pelvic of urethral trauma
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

30. Complications of breast impant
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

31. diarrhoea 4-5 days after cholecystectomy
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Displaced ORIF ; nondisplaced sling immobilization

32. common complication of inadequate mx of scaphoid fx
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
When urethral catherization is unsuccessful
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
Nonunion and avascular necrosis; fx can block blood supply;

33. What is hungry bone syndrome?
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Nonunion and avascular necrosis; fx can block blood supply;
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

34. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Elevated non seminomas
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

35. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Malignancy until proven otherwise
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

36. most common fx when falling on outsretched hand
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
Unilateral vocal cord paralysis
Klinefelter syndrome; 50 fold increase;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

37. management of stone 8-10mm
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS

38. swelling and tenderness in anterior part of knee
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Patellar tendon tear; difficulty in extension
Dm neuropathy; stocking glove pattern
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

39. indication of ursodeoxycholic acid
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
Even after ochiopexy risk of ochiopexy higher then general population
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

40. Why right varicocele is more concerning?

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41. midline neck swelling moves with protrusion of tongue
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Displaced ORIF ; nondisplaced sling immobilization
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

42. What is most common lung injury after blunt chest trauma?
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

43. Patient underwent CABG; postoperatively drowsy. most likely cause?
Strok and traumatic brain injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Retrograde ejaculation
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

44. What time frame required for bone remodeling
Check ET tube placement if correct needle decompresion
10-12 months
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Patellar tendon tear; difficulty in extension

45. anal sphincter tone
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
S2-S4
Subphrenic abscess or other abdominal abscesses; order US or CT
ACL injury

46. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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;
Ispilateral hypoglossal nerve injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dm neuropathy; stocking glove pattern

47. beta HCG
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Seminomas

48. recurrent laryngeal nerve injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
CRPS
Unilateral vocal cord paralysis
Pure motor stroke; limited neurological dysfunction

49. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
ACL injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If any compressive symptoms eg. dysphagia

50. How to perform lachman test
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur