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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. How varicocele causes testicular atrophy
Unilateral vocal cord paralysis
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Carpal tunnel syndrom

2. severe pain in leg after MVC
Twisting force with the foot fixed on the ground seen in football and basketball games;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

3. management of hip fracture
10-12 months
Patellar tendon tear; difficulty in extension
If patient ambulatory - surgery and pain control; if not nonop mx
24-48 hours of supportive therapy followed by cholecystectomy

4. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

5. lacerated wound in palmer surface of hand. what structure is injured?
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Tendons more likely
Fx displace >1mm - nonunion during followup - osteonecrosis
ACL injury

6. lacunar stroke
24-48 hours of supportive therapy followed by cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pure motor stroke; limited neurological dysfunction

7. menisci injury
Carpal tunnel 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
Twisting force with the foot fixed on the ground seen in football and basketball games;
15-40%; self limiting;doesn't require tx

8. Complications of breast impant
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

9. most common complication of acute cholecystitis
Klinefelter syndrome; 50 fold increase;
Amoxicillin-clavulanate
Patellar tendon tear; difficulty in extension
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

10. midline neck swelling moves with protrusion of tongue
50%; tunneling between rectum or kin
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

11. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

12. How to perform lachman test
If patient ambulatory - surgery and pain control; if not nonop mx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

13. What time frame required for bone remodeling
10-12 months
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
CRPS

14. How to differentiate communicative and non-communicative hydrocele
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
Compression stocking - weight reduction - leg elevation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Increased size during the day and valsalva means it is communicated with peritoneal cavity

15. most frequent complication of TURP
Retrograde ejaculation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Study showed no adverse effect; but they are contraindicated for PVD

16. complication displaced or communited distal radial fx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Carpal tunnel syndrom

17. dorsiflexion and planter flexion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
L5 to S2
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

18. How to confirm achiles tendon rupture
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
Klinefelter syndrome; 50 fold increase;
S2-S4
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

19. What is the contraindication of hyperventilation in inc ICP
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Brardycardia - HTN - resp depression
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;
Strok and traumatic brain injury

20. differential of ultrasound finding of breast mass
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Klinefelter syndrome; 50 fold increase;

21. What are the common injuries from lightning?
CRPS
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
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

22. ct scan; cystic lesion in head of pancreas; next step
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Strok and traumatic brain injury
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

23. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Retrograde ejaculation

24. Valgus and Varus tests
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Patellar tendon tear; difficulty in extension

25. What is most common lung injury after blunt chest trauma?
Displaced ORIF ; nondisplaced sling immobilization
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
Study showed no adverse effect; but they are contraindicated for PVD
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

26. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

27. varicose veins with ulcer - bleeding and thrombophlebitits
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
ACL injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

28. 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;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Ispilateral hypoglossal nerve injury
Next best step surgery; not ultrasound

29. aspiration of breast cyst is nonbloody
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Next best step surgery; not ultrasound
Elevated non seminomas
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

30. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Twisting force with the foot fixed on the ground seen in football and basketball games;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
CRPS
50%; tunneling between rectum or kin

31. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
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

32. varicocele
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Headache - ataxia - bulbar dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
L5 to S2

33. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
When urethral catherization is unsuccessful
Epi and chest compressio for prolong period of time; atropine is given after epi;

34. 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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Meniscus injury; medial most common; pain/swelling; popping sensation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

35. What is cushing's triad
Brardycardia - HTN - resp depression
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

36. pregnant patient with asymptomatic gall stones
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Mammogram
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

37. acalculus cholecystitis
Patellar tendon tear; difficulty in extension
Even after ochiopexy risk of ochiopexy higher then general population
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elderly and critically ill patients

38. management of gunshot wound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Meniscus injury; medial most common; pain/swelling; popping sensation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

39. What types of breast implants are available
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check ET tube placement if correct needle decompresion
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Saline and silicone

40. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Less than 5mm
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

41. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. mx of stress fx
10-12 months
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Displaced ORIF ; nondisplaced sling immobilization
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

43. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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;
4-6 weeks for noncontact sports and longer time for contact sports

44. What is hydrocele?
Displaced ORIF ; nondisplaced sling immobilization
Amoxicillin-clavulanate
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Cystic scrotal fluid collection between parietal and visceral layers of testis

45. 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;
Supraglottic edema; low threshold for intubation
Epi and chest compressio for prolong period of time; atropine is given after epi;
Displaced ORIF ; nondisplaced sling immobilization

46. Why initial xrays are negative in scaphoid fx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
Progressive fibrosis of palmar fascia. etiololgy not known;
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

47. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
ACL injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

48. When to stop raloxifene before surgery
Klinefelter syndrome; 50 fold increase;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

49. DD of acute scrotal pain
24-48 hours of supportive therapy followed by cholecystectomy
S2-S4
Ispilateral hypoglossal nerve injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

50. how hyperventilation lowers ICP
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely