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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. SOB - confusion - petechial rash after trauma - fracture
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Unilateral vocal cord paralysis

2. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Patellar tendon tear; difficulty in extension
4-6 weeks for noncontact sports and longer time for contact sports
Malignancy until proven otherwise
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

3. cremasteric reflex
Urethral stricture; pelvic of urethral trauma
15-40%; self limiting;doesn't require tx
Mammogram
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

4. How to confirm achiles tendon rupture
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

5. Why ruq calcificaion is concerning
Elevated non seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Low anterior resection and radio; add chemo if node positive

6. most frequent complication of TURP
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Retrograde ejaculation
SAH due to post communicating artery aneurysm;
L5 to S2

7. What is cushing's triad
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Brardycardia - HTN - resp depression
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
Headache - ataxia - bulbar dysfunction

8. anal sphincter tone
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Less than 5mm
S2-S4
Carpal tunnel syndrom

9. What is the complications of undescended testis
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;
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
Even after ochiopexy risk of ochiopexy higher then general population
Malignancy until proven otherwise

10. lacunar stroke
Pure motor stroke; limited neurological dysfunction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Low anterior resection and radio; add chemo if node positive

11. differential of ultrasound finding of breast mass
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
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
Retrograde ejaculation

12. What is the strongest risk factor for male breast cancer
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Klinefelter syndrome; 50 fold increase;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

13. management of nondisplaced scaphoid fx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Subphrenic abscess or other abdominal abscesses; order US or CT
Twisting force with the foot fixed on the ground seen in football and basketball games;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

14. Complications of breast impant
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

15. How to perform lachman test
Seminomas
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

16. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
S2-S4
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

17. ct scan; cystic lesion in head of pancreas; next step
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If patient ambulatory - surgery and pain control; if not nonop mx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

18. mx of stress fx
15-40%; self limiting;doesn't require tx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

19. antibiotics of acute cholecystitis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Even after ochiopexy risk of ochiopexy higher then general population
Sphincter sparing surgery (local resection) - abdomnio perineal resection

20. How to confirm dx of compartment syndrom
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
Urethral stricture; pelvic of urethral trauma
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

21. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
S2-S4
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

22. What is prehn sign?
When urethral catherization is unsuccessful
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Ispilateral hypoglossal nerve injury

23. When to do surgery in undesceneded testis?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

24. What is the contraindication of hyperventilation in inc ICP
Epi and chest compressio for prolong period of time; atropine is given after epi;
Strok and traumatic brain injury
Saline and silicone
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

25. several knee pain after being tackled in football game
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

26. Tx of proximal non metastatic rectal ca
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Low anterior resection and radio; add chemo if node positive

27. how hyperventilation lowers ICP
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Meniscus injury; medial most common; pain/swelling; popping sensation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

28. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

29. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Malignancy until proven otherwise
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Meniscus injury; medial most common; pain/swelling; popping sensation

30. contraindication of urethral catheterization
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fx displace >1mm - nonunion during followup - osteonecrosis
SAH due to post communicating artery aneurysm;
Urethral stricture; pelvic of urethral trauma

31. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Supraglottic edema; low threshold for intubation
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

32. When do we see complications due to hypophosphatemia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

33. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If patient ambulatory - surgery and pain control; if not nonop mx
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

34. How to dx ACL tear?
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

35. What is hungry bone syndrome?
Even after ochiopexy risk of ochiopexy higher then general population
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
ACL injury

36. painless testicular mass in young male
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Malignancy until proven otherwise
Patellar tendon tear; difficulty in extension

37. varicocele
Compression stocking - weight reduction - leg elevation
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

38. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fx displace >1mm - nonunion during followup - osteonecrosis

39. Valgus and Varus tests
Progressive fibrosis of palmar fascia. etiololgy not known;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
10-12 months

40. lacerated wound in palmer surface of hand. what structure is injured?
Urethral stricture; pelvic of urethral trauma
Tendons more likely
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Low anterior resection and radio; add chemo if node positive

41. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dm neuropathy; stocking glove pattern
Meniscus injury; medial most common; pain/swelling; popping sensation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

42. most common fx when falling on outsretched hand
Brardycardia - HTN - resp depression
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

43. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Less than 5mm
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Subphrenic abscess or other abdominal abscesses; order US or CT

44. SAH due to posterior inferior cerebellar aneurysm
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Headache - ataxia - bulbar dysfunction
Check ET tube placement if correct needle decompresion

45. acute colonic ischemia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

46. Dupuytren contracture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Progressive fibrosis of palmar fascia. etiololgy not known;
Dumping syndrome; small and frequent meals; no simple sugar

47. What time frame required for bone remodeling
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
10-12 months
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. swelling and tenderness in anterior part of knee
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

49. dorsiflexion and planter flexion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
SAH due to post communicating artery aneurysm;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
L5 to S2

50. Indication for bariatric surgery in obese patients
SAH due to post communicating artery aneurysm;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;