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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. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
4-6 weeks for noncontact sports and longer time for contact sports
Seminomas

2. complication displaced or communited distal radial fx
CRPS
Carpal tunnel syndrom
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;

3. anal sphincter tone
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Less than 5mm
S2-S4
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

4. sudden onset of postoperative hyperglycemia when patient on TPN
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

5. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
If any compressive symptoms eg. dysphagia
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

6. management of gunshot wound
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Retrograde ejaculation
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

7. how hyperventilation lowers ICP
Klinefelter syndrome; 50 fold increase;
Next best step surgery; not ultrasound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Headache - ataxia - bulbar dysfunction

8. complications of TPN
Saline and silicone
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

9. How to manage obesity
Tendons more likely
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;
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

10. What percent of anal abscess deveolop fisutula
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
50%; tunneling between rectum or kin
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
15-40%; self limiting;doesn't require tx

11. When to stop raloxifene before surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
15-40%; self limiting;doesn't require tx
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

12. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Supraglottic edema; low threshold for intubation
CRPS
Headache - ataxia - bulbar dysfunction

13. managment of animal bite in hands
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;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Compression stocking - weight reduction - leg elevation

14. acute colonic ischemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Mammogram
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
Abd pain and tenderness; bloody diarrhoea or hematochezia

15. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cystic scrotal fluid collection between parietal and visceral layers of testis

16. How to differentiate communicative and non-communicative hydrocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

17. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Check ET tube placement if correct needle decompresion

18. most frequent complication of TURP
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Study showed no adverse effect; but they are contraindicated for PVD
Retrograde ejaculation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

19. How to confirm achiles tendon rupture
Tendons more likely
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

20. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Progressive fibrosis of palmar fascia. etiololgy not known;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pure motor stroke; limited neurological dysfunction

21. Why right varicocele is more concerning?

22. cat/dog bites
Amoxicillin-clavulanate
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
15-40%; self limiting;doesn't require tx

23. varicocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

24. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

26. differential of ultrasound finding of breast mass
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

27. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Twisting force with the foot fixed on the ground seen in football and basketball games;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

28. What are the common injuries from lightning?
Urethral stricture; pelvic of urethral trauma
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

29. When do we see complications due to hypophosphatemia
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Elderly and critically ill patients
Nonunion and avascular necrosis; fx can block blood supply;

30. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

31. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Study showed no adverse effect; but they are contraindicated for PVD
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

32. indication of ursodeoxycholic acid
SAH due to post communicating artery aneurysm;
Displaced ORIF ; nondisplaced sling immobilization
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

33. surgery for acute cholecystities
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
24-48 hours of supportive therapy followed by cholecystectomy
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

34. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Tendons more likely
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ACL injury

35. transrectal prostate biopsy
Epi and chest compressio for prolong period of time; atropine is given after epi;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
When urethral catherization is unsuccessful
50%; tunneling between rectum or kin

36. 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.
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Amoxicillin-clavulanate

37. suprapubic catheterization
When urethral catherization is unsuccessful
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Elderly and critically ill patients

38. Most common of sudden death due to steering wheel injury
Supraglottic edema; low threshold for intubation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

39. cremasteric reflex
Displaced ORIF ; nondisplaced sling immobilization
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

40. What is terrible triad
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

41. What is prehn sign?
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Seminomas
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

42. 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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
ACL injury

43. diarrhoea after gastric bypass
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar

44. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
Next best step surgery; not ultrasound
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Check ET tube placement if correct needle decompresion

45. When goiter needs surgery
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If any compressive symptoms eg. dysphagia
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

46. painless testicular mass in young male
Brardycardia - HTN - resp depression
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
Malignancy until proven otherwise
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

47. How to dx ACL tear?
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Elevated non seminomas
Even after ochiopexy risk of ochiopexy higher then general population
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

48. pregnant patient with asymptomatic gall stones
When urethral catherization is unsuccessful
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

49. types of hip fracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

50. What types of breast implants are available
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Supraglottic edema; low threshold for intubation