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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. SAH due to posterior inferior cerebellar aneurysm
4-6 weeks for noncontact sports and longer time for contact sports
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Headache - ataxia - bulbar dysfunction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

2. What is the complications of undescended testis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Even after ochiopexy risk of ochiopexy higher then general population
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Saline and silicone

3. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Patellar tendon tear; difficulty in extension
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

4. dorsiflexion and planter flexion
Malignancy until proven otherwise
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
L5 to S2

5. inhalation of hot air - steam - smoke in burn victim
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Supraglottic edema; low threshold for intubation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Study showed no adverse effect; but they are contraindicated for PVD

6. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
When urethral catherization is unsuccessful
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Amoxicillin-clavulanate
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

7. What is most common lung injury after blunt chest trauma?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

8. dumping syndrome after gastrectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

9. How to differentiate ACL and meniscus injury
Strok and traumatic brain injury
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; 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
Abd pain and tenderness; bloody diarrhoea or hematochezia

10. indication of ursodeoxycholic acid
Seminomas
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Less than 5mm

11. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Abd pain and tenderness; bloody diarrhoea or hematochezia

12. How to differentiate communicative and non-communicative hydrocele
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

13. How to manage obesity
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

14. Why varicocele more common in the left side
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Klinefelter syndrome; 50 fold increase;
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

15. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Increased size during the day and valsalva means it is communicated with peritoneal cavity

16. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Epi and chest compressio for prolong period of time; atropine is given after epi;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

17. Tx of proximal non metastatic rectal ca
Nonunion and avascular necrosis; fx can block blood supply;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Low anterior resection and radio; add chemo if node positive
Brardycardia - HTN - resp depression

18. diarrhoea 4-5 days after cholecystectomy
Pure motor stroke; limited neurological dysfunction
Urethral stricture; pelvic of urethral trauma
Sphincter sparing surgery (local resection) - abdomnio perineal resection
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

19. clavicle fx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Displaced ORIF ; nondisplaced sling immobilization
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

20. How to confirm achiles tendon rupture
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
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elderly and critically ill patients

21. Tx of pulmonary contusion
S2-S4
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Malignancy until proven otherwise

22. beta hcg and AFP
Tendons more likely
Elevated non seminomas
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Next best step surgery; not ultrasound

23. transrectal prostate biopsy
Displaced ORIF ; nondisplaced sling immobilization
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

24. How mcmurray manuver perform
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

25. ct scan; cystic lesion in head of pancreas; next step
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;

26. menisci injury
Fx displace >1mm - nonunion during followup - osteonecrosis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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;

27. How to evaluate painless testicular swelling suspicious for cancer
Compression stocking - weight reduction - leg elevation
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

28. mx of stress fx
Mammogram
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Ispilateral hypoglossal nerve injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

29. What is the strongest risk factor for male breast cancer
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
Next best step surgery; not ultrasound
Elevated non seminomas
Klinefelter syndrome; 50 fold increase;

30. When to do surgery in undesceneded testis?
Brardycardia - HTN - resp depression
Urethral stricture; pelvic of urethral trauma
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

31. What is hydrocele?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
CRPS
Cystic scrotal fluid collection between parietal and visceral layers of testis

32. what size of ureteral stone for non op mx
Less than 5mm
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

33. What are the common injuries from lightning?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Study showed no adverse effect; but they are contraindicated for PVD
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

34. stress fx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Headache - ataxia - bulbar dysfunction
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

36. when patient with severe lung disease have C02 retention
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

37. prostate enlarged - nontender - no nodularity - elevated PSA
Strok and traumatic brain injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues 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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

38. painless testicular mass in young male
Study showed no adverse effect; but they are contraindicated for PVD
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Malignancy until proven otherwise
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

39. What types of breast implants are available
Even after ochiopexy risk of ochiopexy higher then general population
Meniscus injury; medial most common; pain/swelling; popping sensation
Ispilateral hypoglossal nerve injury
Saline and silicone

40. types of hip fracture
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

41. How to manage a patient with asystole
Malignancy until proven otherwise
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
If any compressive symptoms eg. dysphagia
Epi and chest compressio for prolong period of time; atropine is given after epi;

42. What is hungry bone syndrome?
Mammogram
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
Elderly and critically ill patients
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

43. What is the contraindication of hyperventilation in inc ICP
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Even after ochiopexy risk of ochiopexy higher then general population
Strok and traumatic brain injury

44. swelling and tenderness in anterior part of knee
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Patellar tendon tear; difficulty in extension
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

45. acute colonic ischemia
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Meniscus injury; medial most common; pain/swelling; popping sensation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Brardycardia - HTN - resp depression

46. When do we see complications due to hypophosphatemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

47. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

48. pregnant patient with asymptomatic gall stones
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Nonunion and avascular necrosis; fx can block blood supply;
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;

49. What is prehn sign?
50%; tunneling between rectum or kin
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
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

50. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
10-12 months
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)