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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. What is the strongest risk factor for male breast cancer
50%; tunneling between rectum or kin
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Klinefelter syndrome; 50 fold increase;

2. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abd pain and tenderness; bloody diarrhoea or hematochezia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

3. Complications of breast impant
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

4. What types of breast implants are available
Abd pain and tenderness; bloody diarrhoea or hematochezia
Saline and silicone
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
CRPS

5. severe pain in leg after MVC
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

6. acalculus cholecystitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Elderly and critically ill patients
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

7. anal sphincter tone
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
S2-S4
If patient ambulatory - surgery and pain control; if not nonop mx
Increased size during the day and valsalva means it is communicated with peritoneal cavity

8. What is the complications of undescended testis
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population

9. Indication for bariatric surgery in obese patients
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Tendons more likely
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

10. What is the contraindication of hyperventilation in inc ICP
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Ispilateral hypoglossal nerve injury
Strok and traumatic brain injury
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. painless testicular mass in young male
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Malignancy until proven otherwise
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

12. menisci injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
SAH due to post communicating artery aneurysm;
Twisting force with the foot fixed on the ground seen in football and basketball games;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

13. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dm neuropathy; stocking glove pattern

14. Dupuytren contracture
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Strok and traumatic brain injury
<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;

15. What is prehn sign?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Strok and traumatic brain injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Klinefelter syndrome; 50 fold increase;

16. scrotal trauma
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Brardycardia - HTN - resp depression
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;
Next best step surgery; not ultrasound

17. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Carpal tunnel syndrom
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

18. what size of ureteral stone for non op mx
Less than 5mm
Headache - ataxia - bulbar dysfunction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dm neuropathy; stocking glove pattern

19. What are the common injuries from lightning?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
15-40%; self limiting;doesn't require tx

20. What time frame required for bone remodeling
Low anterior resection and radio; add chemo if node positive
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

21. when patient with severe lung disease have C02 retention
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
10-12 months
Compression stocking - weight reduction - leg elevation
Abd pain and tenderness; bloody diarrhoea or hematochezia

22. dorsiflexion and planter flexion
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Pure motor stroke; limited neurological dysfunction
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

23. Why right varicocele is more concerning?

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24. varicose veins with ulcer - bleeding and thrombophlebitits
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)
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

25. most common fx when falling on outsretched hand
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Elevated non seminomas
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;

26. mangement of localized lymphadenopathy
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Seminomas

27. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

28. transrectal prostate biopsy
Unilateral vocal cord paralysis
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

29. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Twisting force with the foot fixed on the ground seen in football and basketball games;
CRPS
Check ET tube placement if correct needle decompresion
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

30. How to manage obesity
Dm neuropathy; stocking glove pattern
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
L5 to S2
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

31. How to dx ACL tear?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
If patient ambulatory - surgery and pain control; if not nonop mx
Dumping syndrome; small and frequent meals; no simple sugar

32. 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;
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

33. Can we use beta blocker for pvd?
Even after ochiopexy risk of ochiopexy higher then general population
Study showed no adverse effect; but they are contraindicated for PVD
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Saline and silicone

34. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Amoxicillin-clavulanate
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Low anterior resection and radio; add chemo if node positive

35. most common complication 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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
S2-S4
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

36. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
If any compressive symptoms eg. dysphagia
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
Klinefelter syndrome; 50 fold increase;
CRPS

37. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Epi and chest compressio for prolong period of time; atropine is given after epi;

38. stress fx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

39. popping sensation; rapid onset of knee effusion. athelet
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
ACL injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Increased size during the day and valsalva means it is communicated with peritoneal cavity

40. xray finding of stress fx after 3-4w
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dumping syndrome; small and frequent meals; no simple sugar
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

41. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
CRPS

42. SAH due to posterior inferior cerebellar aneurysm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Headache - ataxia - bulbar dysfunction
Nonunion and avascular necrosis; fx can block blood supply;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

43. How to differentiate ACL and meniscus injury
CRPS
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
10-12 months
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

44. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

45. management of nondisplaced scaphoid fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
SAH due to post communicating artery aneurysm;
15-40%; self limiting;doesn't require tx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

46. diarrhoea after gastric bypass
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Headache - ataxia - bulbar dysfunction
Dumping syndrome; small and frequent meals; no simple sugar

47. How to perform lachman test
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Mammogram
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

48. How varicocele causes testicular atrophy
Brardycardia - HTN - resp depression
Supraglottic edema; low threshold for intubation
4-6 weeks for noncontact sports and longer time for contact sports
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

49. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Patellar tendon tear; difficulty in extension
L5 to S2
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

50. aspiration of breast cyst is nonbloody
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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