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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 to differentiate communicative and non-communicative hydrocele
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Increased size during the day and valsalva means it is communicated with peritoneal cavity

2. Tx of proximal non metastatic rectal ca
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;
Low anterior resection and radio; add chemo if node positive
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

3. sudden onset of postoperative hyperglycemia when patient on TPN
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Displaced ORIF ; nondisplaced sling immobilization
50%; tunneling between rectum or kin
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

4. prostate enlarged - nontender - no nodularity - elevated PSA
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
Pure motor stroke; limited neurological dysfunction
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

5. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
S2-S4
Urethral stricture; pelvic of urethral trauma
50%; tunneling between rectum or kin

6. Why initial xrays are negative in scaphoid fx
Displaced ORIF ; nondisplaced sling immobilization
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
If any compressive symptoms eg. dysphagia

7. management of stone 8-10mm
4-6 weeks for noncontact sports and longer time for contact sports
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

8. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Low anterior resection and radio; add chemo if node positive
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dm neuropathy; stocking glove pattern
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

9. Tx of pulmonary contusion
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Low anterior resection and radio; add chemo if node positive
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

10. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
SAH due to post communicating artery aneurysm;

11. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Meniscus injury; medial most common; pain/swelling; popping sensation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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

12. Valgus and Varus tests
Subphrenic abscess or other abdominal abscesses; order US or CT
Cystic scrotal fluid collection between parietal and visceral layers of testis
Amoxicillin-clavulanate
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

13. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Study showed no adverse effect; but they are contraindicated for PVD
Seminomas
Low anterior resection and radio; add chemo if node positive

14. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dumping syndrome; small and frequent meals; no simple sugar
15-40%; self limiting;doesn't require tx
Patellar tendon tear; difficulty in extension

15. conservative Tx of varicose veins
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Compression stocking - weight reduction - leg elevation
If any compressive symptoms eg. dysphagia

16. When goiter needs surgery
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Elevated non seminomas
If any compressive symptoms eg. dysphagia
Even after ochiopexy risk of ochiopexy higher then general population

17. beta HCG
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Strok and traumatic brain injury

18. How to manage a patient with asystole
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Nonunion and avascular necrosis; fx can block blood supply;

19. painless testicular mass in young male
Malignancy until proven otherwise
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Abd pain and tenderness; bloody diarrhoea or hematochezia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

20. management of hip fracture
Tendons more likely
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
If patient ambulatory - surgery and pain control; if not nonop mx
MAT; medial meniscus injury; ACL and Tibial colateral ligament

21. beta hcg and AFP
Twisting force with the foot fixed on the ground seen in football and basketball games;
Elevated non seminomas
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

22. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

23. What is hydrocele?
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cystic scrotal fluid collection between parietal and visceral layers of testis

24. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

25. How to manage obesity
Urethral stricture; pelvic of urethral trauma
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
10-12 months
Abd pain and tenderness; bloody diarrhoea or hematochezia

26. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Unilateral vocal cord paralysis

27. scrotal trauma
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4-6 weeks for noncontact sports and longer time for contact sports
Next best step surgery; not ultrasound
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

28. How varicocele causes testicular atrophy
SAH due to post communicating artery aneurysm;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Twisting force with the foot fixed on the ground seen in football and basketball games;

29. What is the contraindication of hyperventilation in inc ICP
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Mammogram
Strok and traumatic brain injury

30. how ABI help dx of PVD
SAH due to post communicating artery aneurysm;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

31. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS

32. dumping syndrome after gastrectomy
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

33. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

34. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Ispilateral hypoglossal nerve injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

35. complications of TPN
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

36. clavicle fx
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
Displaced ORIF ; nondisplaced sling immobilization
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

37. What are the common injuries from lightning?
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
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

38. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
CRPS

39. suprapubic catheterization
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
Carpal tunnel syndrom
When urethral catherization is unsuccessful
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
SAH due to post communicating artery aneurysm;
Check ET tube placement if correct needle decompresion

41. Can we use beta blocker for pvd?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Study showed no adverse effect; but they are contraindicated for PVD
Malignancy until proven otherwise
Check ET tube placement if correct needle decompresion

42. Why right varicocele is more concerning?

43. when scaphoid fx patient needs to be referred to orthopedic
Brardycardia - HTN - resp depression
Dm neuropathy; stocking glove pattern
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis

44. What types of breast implants are available
Saline and silicone
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Elderly and critically ill patients
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

45. inhalation of hot air - steam - smoke in burn victim
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
Supraglottic edema; low threshold for intubation
Check ET tube placement if correct needle decompresion
Seminomas

46. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dm neuropathy; stocking glove pattern
CRPS
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

47. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
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;

48. lacerated wound in palmer surface of hand. what structure is injured?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Tendons more likely
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Mammogram

49. antibiotics of acute cholecystitis
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

50. management of gunshot wound
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Nonunion and avascular necrosis; fx can block blood supply;