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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
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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. most frequent complication of TURP
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Retrograde ejaculation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

2. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Progressive fibrosis of palmar fascia. etiololgy not known;
50%; tunneling between rectum or kin
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

3. What is the contraindication of hyperventilation in inc ICP
Even after ochiopexy risk of ochiopexy higher then general population
Strok and traumatic brain injury
Retrograde ejaculation
Meniscus injury; medial most common; pain/swelling; popping sensation

4. 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
10-12 months
Subphrenic abscess or other abdominal abscesses; order US or CT
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

5. cat/dog bites
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Amoxicillin-clavulanate
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

6. How to confirm achiles tendon rupture
Brardycardia - HTN - resp depression
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dm neuropathy; stocking glove pattern
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

7. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
4-6 weeks for noncontact sports and longer time for contact sports
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

8. acalculus cholecystitis
Elderly and critically ill patients
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Sphincter sparing surgery (local resection) - abdomnio perineal resection

9. management of gunshot wound
Klinefelter syndrome; 50 fold increase;
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
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
Urethral stricture; pelvic of urethral trauma

10. 3 mo with groin bulge; bulge appears when child cries
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

11. How to confirm dx of compartment syndrom
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

12. What is terrible triad
50%; tunneling between rectum or kin
Progressive fibrosis of palmar fascia. etiololgy not known;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

13. lacunar stroke
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
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
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

14. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Brardycardia - HTN - resp depression

15. surgery for acute cholecystities
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
24-48 hours of supportive therapy followed by cholecystectomy
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

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
CRPS
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

17. complication displaced or communited distal radial fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Carpal tunnel syndrom
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

18. Valgus and Varus tests
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

19. painless testicular mass in young male
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;
Malignancy until proven otherwise
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

20. tx distal rectal ca
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Unilateral vocal cord paralysis
Seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection

21. several knee pain after being tackled in football game
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Urethral stricture; pelvic of urethral trauma
Ispilateral hypoglossal nerve injury

22. management of hip fracture
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
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

23. What types of breast implants are available
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Saline and silicone
Displaced ORIF ; nondisplaced sling immobilization
Elderly and critically ill patients

24. 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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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;
CRPS
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

26. how ABI help dx of PVD
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Nonunion and avascular necrosis; fx can block blood supply;
Study showed no adverse effect; but they are contraindicated for PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

27. when scaphoid fx patient needs to be referred to orthopedic
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Strok and traumatic brain injury
50%; tunneling between rectum or kin
Fx displace >1mm - nonunion during followup - osteonecrosis

28. What are the common injuries from lightning?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Seminomas

29. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Retrograde ejaculation
15-40%; self limiting;doesn't require tx

30. first step for evaluation of testicular swelling
15-40%; self limiting;doesn't require tx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

31. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Amoxicillin-clavulanate

32. suprapubic catheterization
When urethral catherization is unsuccessful
Meniscus injury; medial most common; pain/swelling; popping sensation
Dm neuropathy; stocking glove pattern
Ispilateral hypoglossal nerve injury

33. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Check ET tube placement if correct needle decompresion
MAT; medial meniscus injury; ACL and Tibial colateral ligament

34. recurrent laryngeal nerve injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

35. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Less than 5mm

36. popping sensation; rapid onset of knee effusion. athelet
Saline and silicone
CRPS
ACL injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

37. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Klinefelter syndrome; 50 fold increase;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Subphrenic abscess or other abdominal abscesses; order US or CT
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

38. when patient with severe lung disease have C02 retention
Meniscus injury; medial most common; pain/swelling; popping sensation
Headache - ataxia - bulbar dysfunction
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

39. beta HCG
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Seminomas

40. How to differentiate ACL and meniscus injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

41. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pure motor stroke; limited neurological dysfunction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

42. What is prehn sign?
S2-S4
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports

43. dumping syndrome after gastrectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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.
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

44. common complication of inadequate mx of scaphoid fx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
15-40%; self limiting;doesn't require tx
Nonunion and avascular necrosis; fx can block blood supply;

45. How to dx ACL tear?
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
If patient ambulatory - surgery and pain control; if not nonop mx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

46. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

47. ipsilateral deviation of tongue upon protrusion
When urethral catherization is unsuccessful
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Ispilateral hypoglossal nerve injury
Headache - ataxia - bulbar dysfunction

48. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Klinefelter syndrome; 50 fold increase;

49. What percent of anal abscess deveolop fisutula
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
50%; tunneling between rectum or kin
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

50. Why right varicocele is more concerning?

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