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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. severe pain in leg after MVC
Patellar tendon tear; difficulty in extension
Subphrenic abscess or other abdominal abscesses; order US or CT
Malignancy until proven otherwise
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

2. aspiration of breast cyst is nonbloody
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
Next best step surgery; not ultrasound
L5 to S2
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

3. anal sphincter tone
S2-S4
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

4. cremasteric reflex test?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Sphincter sparing surgery (local resection) - abdomnio perineal resection
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

5. What is hydrocele?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Cystic scrotal fluid collection between parietal and visceral layers of testis

6. What is the complications of undescended testis
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Even after ochiopexy risk of ochiopexy higher then general population
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

7. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Nonunion and avascular necrosis; fx can block blood supply;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

8. dumping syndrome after gastrectomy
Elderly and critically ill patients
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

9. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Malignancy until proven otherwise
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

10. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Urethral stricture; pelvic of urethral trauma
SAH due to post communicating artery aneurysm;
If patient ambulatory - surgery and pain control; if not nonop mx
Abd pain and tenderness; bloody diarrhoea or hematochezia

11. management of stone 8-10mm
Seminomas
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone

12. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
10-12 months

13. beta hcg and AFP
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Ispilateral hypoglossal nerve injury
Elevated non seminomas

14. What percent of anal abscess deveolop fisutula
Brardycardia - HTN - resp depression
50%; tunneling between rectum or kin
Elderly and critically ill patients
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

15. contraindication of urethral catheterization
When urethral catherization is unsuccessful
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Urethral stricture; pelvic of urethral trauma
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

16. ipsilateral deviation of tongue upon protrusion
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ispilateral hypoglossal nerve 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
Malignancy until proven otherwise

17. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Abd pain and tenderness; bloody diarrhoea or hematochezia

18. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Urethral stricture; pelvic of urethral trauma

19. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Progressive fibrosis of palmar fascia. etiololgy not known;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Check ET tube placement if correct needle decompresion
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

20. How to manage a patient with asystole
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Low anterior resection and radio; add chemo if node positive
Strok and traumatic brain injury
Epi and chest compressio for prolong period of time; atropine is given after epi;

21. complication displaced or communited distal radial fx
Carpal tunnel syndrom
CRPS
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Abd pain and tenderness; bloody diarrhoea or hematochezia

22. cremasteric reflex
4-6 weeks for noncontact sports and longer time for contact sports
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Retrograde ejaculation
Low anterior resection and radio; add chemo if node positive

23. Valgus and Varus tests
S2-S4
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
ACL injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

24. types of hip fracture
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
50%; tunneling between rectum or kin
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

25. antibiotics of acute cholecystitis
Brardycardia - HTN - resp depression
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

26. complications of TPN
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
24-48 hours of supportive therapy followed by cholecystectomy
Headache - ataxia - bulbar dysfunction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

27. Can we use beta blocker for pvd?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
S2-S4
Study showed no adverse effect; but they are contraindicated for PVD
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

28. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

29. How to confirm dx of compartment syndrom
Study showed no adverse effect; but they are contraindicated for PVD
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

30. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

31. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
If any compressive symptoms eg. dysphagia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

32. most common fx when falling on outsretched hand
Pure motor stroke; limited neurological dysfunction
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
When urethral catherization is unsuccessful

33. surgery for acute cholecystities
If any compressive symptoms eg. dysphagia
24-48 hours of supportive therapy followed by cholecystectomy
Tendons more likely
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

34. What is most common lung injury after blunt chest trauma?
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

35. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Displaced ORIF ; nondisplaced sling immobilization
Study showed no adverse effect; but they are contraindicated for PVD

36. beta HCG
Check ET tube placement if correct needle decompresion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. scrotal trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
50%; tunneling between rectum or kin
Next best step surgery; not ultrasound
Tendons more likely

38. Indication for bariatric surgery in obese patients
Progressive fibrosis of palmar fascia. etiololgy not known;
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
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;

39. Why ruq calcificaion is concerning
Carpal tunnel syndrom
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Brardycardia - HTN - resp depression

40. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Elevated non seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection

41. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dumping syndrome; small and frequent meals; no simple sugar
Dm neuropathy; stocking glove pattern

42. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

43. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Carpal tunnel syndrom
Pure motor stroke; limited neurological dysfunction
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Subphrenic abscess or other abdominal abscesses; order US or CT

44. when patient with severe lung disease have C02 retention
4-6 weeks for noncontact sports and longer time for contact sports
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

45. most frequent complication of TURP
Fx displace >1mm - nonunion during followup - osteonecrosis
10-12 months
Retrograde ejaculation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

46. When patient can go back to sports after clavicle fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4-6 weeks for noncontact sports and longer time for contact sports
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

47. sudden onset of postoperative hyperglycemia when patient on TPN
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Strok and traumatic brain injury

48. how ABI help dx of PVD
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Next best step surgery; not ultrasound
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

49. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
50%; tunneling between rectum or kin
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Meniscus injury; medial most common; pain/swelling; popping sensation

50. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Elderly and critically ill patients
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal