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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. anal sphincter tone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
S2-S4

2. How to manage a patient with asystole
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Epi and chest compressio for prolong period of time; atropine is given after epi;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2

3. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
15-40%; self limiting;doesn't require tx

4. what size of ureteral stone for non op mx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Less than 5mm

5. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Next best step surgery; not ultrasound
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

6. What is the contraindication of hyperventilation in inc ICP
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
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
S2-S4
Strok and traumatic brain injury

7. conservative Tx of varicose veins
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
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
Compression stocking - weight reduction - leg elevation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

8. cremasteric reflex
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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Displaced ORIF ; nondisplaced sling immobilization

9. perioral numbness after parathyroidectomy
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;
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
Headache - ataxia - bulbar dysfunction

10. midline neck swelling moves with protrusion of tongue
Twisting force with the foot fixed on the ground seen in football and basketball games;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
S2-S4
Patellar tendon tear; difficulty in extension

11. What is prehn sign?
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
10-12 months
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

12. 27 yo with scrotal mass; warm tender testes feel like bag of worms
50%; tunneling between rectum or kin
CRPS
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

13. menisci injury
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Twisting force with the foot fixed on the ground seen in football and basketball games;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

14. several knee pain after being tackled in football game
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

15. how hyperventilation lowers ICP
Nonunion and avascular necrosis; fx can block blood supply;
Next best step surgery; not ultrasound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
L5 to S2

16. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
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
Subphrenic abscess or other abdominal abscesses; order US or CT

17. What is cushing's triad
Carpal tunnel syndrom
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Brardycardia - HTN - resp depression

18. What is hungry bone syndrome?
Even after ochiopexy risk of ochiopexy higher then general population
If patient ambulatory - surgery and pain control; if not nonop mx
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

19. How to evaluate painless testicular swelling suspicious for cancer
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

20. dumping syndrome after gastrectomy
Headache - ataxia - bulbar dysfunction
Mammogram
Low anterior resection and radio; add chemo if node positive
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

21. How to manage obesity
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
10-12 months

22. How varicocele causes testicular atrophy
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If any compressive symptoms eg. dysphagia

23. most frequent complication of TURP
ACL injury
Retrograde ejaculation
Elderly and critically ill patients
24-48 hours of supportive therapy followed by cholecystectomy

24. lacerated wound in palmer surface of hand. what structure is injured?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Klinefelter syndrome; 50 fold increase;

25. Tx of proximal non metastatic rectal ca
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Ispilateral hypoglossal nerve injury
Low anterior resection and radio; add chemo if node positive
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

26. common complication of inadequate mx of scaphoid fx
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
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Nonunion and avascular necrosis; fx can block blood supply;

27. beta HCG
Seminomas
Cystic scrotal fluid collection between parietal and visceral layers of testis
Patellar tendon tear; difficulty in extension
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

28. Can we use beta blocker for pvd?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Headache - ataxia - bulbar dysfunction
Meniscus injury; medial most common; pain/swelling; popping sensation
Study showed no adverse effect; but they are contraindicated for PVD

29. Why initial xrays are negative in scaphoid fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

30. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

31. 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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Unilateral vocal cord paralysis
Twisting force with the foot fixed on the ground seen in football and basketball games;

32. painless testicular mass in young male
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Elderly and critically ill patients
Malignancy until proven otherwise
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

33. cat/dog bites
Dumping syndrome; small and frequent meals; no simple sugar
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Amoxicillin-clavulanate
15-40%; self limiting;doesn't require tx

34. managment of animal bite in hands
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
Seminomas
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;

35. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Headache - ataxia - bulbar dysfunction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Study showed no adverse effect; but they are contraindicated for PVD

36. surgery for acute cholecystities
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Malignancy until proven otherwise
24-48 hours of supportive therapy followed by cholecystectomy
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;

37. How to perform lachman test
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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 flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Malignancy until proven otherwise

38. 3 mo with groin bulge; bulge appears when child cries
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. aspiration of breast cyst is nonbloody
Urethral stricture; pelvic of urethral trauma
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

40. aspiration of breast cyst is bloody
24-48 hours of supportive therapy followed by cholecystectomy
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Elderly and critically ill patients
Mammogram

41. management of hip fracture
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.
Even after ochiopexy risk of ochiopexy higher then general population
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

42. severe pain in leg after MVC
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Strok and traumatic brain injury
Meniscus injury; medial most common; pain/swelling; popping sensation
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

43. How to differentiate communicative and non-communicative hydrocele
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
Unilateral vocal cord paralysis
Increased size during the day and valsalva means it is communicated with peritoneal cavity

44. How to confirm achiles tendon rupture
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
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

45. popping sensation; rapid onset of knee effusion. athelet
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
ACL injury

46. What is most common lung injury after blunt chest trauma?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Next best step surgery; not ultrasound
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

47. mx of stress fx
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

48. When to stop raloxifene before surgery
Twisting force with the foot fixed on the ground seen in football and basketball games;
Meniscus injury; medial most common; pain/swelling; popping sensation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

49. prostate enlarged - nontender - no nodularity - elevated PSA
Amoxicillin-clavulanate
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

50. dorsiflexion and planter flexion
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
L5 to S2