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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. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
15-40%; self limiting;doesn't require tx
S2-S4

2. How to manage obesity
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
50%; tunneling between rectum or kin
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

3. beta HCG
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Fx displace >1mm - nonunion during followup - osteonecrosis
Seminomas

4. suprapubic catheterization
When urethral catherization is unsuccessful
Patellar tendon tear; difficulty in extension
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
ACL injury

5. Incidence of AF in CABG patient

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6. 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
Strok and traumatic brain injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

7. What types of breast implants are available
Saline and silicone
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Displaced ORIF ; nondisplaced sling immobilization

8. inhalation of hot air - steam - smoke in burn victim
50%; tunneling between rectum or kin
Supraglottic edema; low threshold for intubation
Fx displace >1mm - nonunion during followup - osteonecrosis
Next best step surgery; not ultrasound

9. mangement of localized lymphadenopathy
Strok and traumatic brain injury
CRPS
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

10. cat/dog bites
Strok and traumatic brain injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Amoxicillin-clavulanate
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

11. menisci injury
Check ET tube placement if correct needle decompresion
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
Urethral stricture; pelvic of urethral trauma

12. swelling and tenderness in anterior part of knee
CRPS
Patellar tendon tear; difficulty in extension
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
Carpal tunnel syndrom

13. What is hungry bone syndrome?
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Low anterior resection and radio; add chemo if node positive
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
Elevated non seminomas

14. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
When urethral catherization is unsuccessful
Seminomas
SAH due to post communicating artery aneurysm;

15. differential of ultrasound finding of breast mass
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
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
10-12 months

16. transrectal prostate biopsy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
24-48 hours of supportive therapy followed by cholecystectomy
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

17. ct scan; cystic lesion in head of pancreas; next step
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ACL injury

18. When to stop raloxifene before surgery
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

19. Indication for bariatric surgery in obese patients
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Displaced ORIF ; nondisplaced sling immobilization
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;
Headache - ataxia - bulbar dysfunction

20. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
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

21. varicocele
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
50%; tunneling between rectum or kin
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

22. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Elevated non seminomas
Strok and traumatic brain injury
Meniscus injury; medial most common; pain/swelling; popping sensation

23. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

24. antibiotics of acute cholecystitis
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Brardycardia - HTN - resp depression

25. What time frame required for bone remodeling
10-12 months
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
Elevated non seminomas
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

26. How varicocele causes testicular atrophy
Dm neuropathy; stocking glove pattern
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

27. management of gunshot wound
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
Amoxicillin-clavulanate
Patellar tendon tear; difficulty in extension
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

28. How to differentiate communicative and non-communicative hydrocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

29. lacunar stroke
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
Retrograde ejaculation
Pure motor stroke; limited neurological dysfunction
When urethral catherization is unsuccessful

30. first line of management of PVD
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
When urethral catherization is unsuccessful
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

31. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If patient ambulatory - surgery and pain control; if not nonop mx
Saline and silicone

32. dorsiflexion and planter flexion
L5 to S2
Urethral stricture; pelvic of urethral trauma
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dumping syndrome; small and frequent meals; no simple sugar

33. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Retrograde ejaculation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

34. Why ruq calcificaion is concerning
Even after ochiopexy risk of ochiopexy higher then general population
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Headache - ataxia - bulbar dysfunction

35. Most common of sudden death due to steering wheel injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
SAH due to post communicating artery aneurysm;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abd pain and tenderness; bloody diarrhoea or hematochezia

36. Patient underwent CABG; postoperatively drowsy. most likely cause?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Carpal tunnel syndrom
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
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

37. How to confirm achiles tendon rupture
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

38. sudden onset of postoperative hyperglycemia when patient on TPN
Next best step surgery; not ultrasound
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

39. stress fx
Fx displace >1mm - nonunion during followup - osteonecrosis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

40. SOB - confusion - petechial rash after trauma - fracture
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

41. aspiration of breast cyst is nonbloody
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If any compressive symptoms eg. dysphagia

42. Dupuytren contracture
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Progressive fibrosis of palmar fascia. etiololgy not known;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

43. complication displaced or communited distal radial fx
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Carpal tunnel syndrom
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

44. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Strok and traumatic brain injury

45. What is cushing's triad
Elderly and critically ill patients
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Brardycardia - HTN - resp depression

46. mx of stress fx
10-12 months
Epi and chest compressio for prolong period of time; atropine is given after epi;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

47. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

48. perioral numbness after parathyroidectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
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;
Supraglottic edema; low threshold for intubation

49. painless testicular mass in young male
10-12 months
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Malignancy until proven otherwise

50. How to dx ACL tear?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abd pain and tenderness; bloody diarrhoea or hematochezia