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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. Why right varicocele is more concerning?

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2. stress fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Check ET tube placement if correct needle decompresion

3. How to evaluate painless testicular swelling suspicious for cancer
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check ET tube placement if correct needle decompresion
Subphrenic abscess or other abdominal abscesses; order US or CT

4. Can we use beta blocker for pvd?
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dm neuropathy; stocking glove pattern
Study showed no adverse effect; but they are contraindicated for PVD
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

5. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Even after ochiopexy risk of ochiopexy higher then general population
Amoxicillin-clavulanate
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
L5 to S2

6. characteristics of ureteral stone?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

7. When to do surgery in undesceneded testis?
When urethral catherization is unsuccessful
Compression stocking - weight reduction - leg elevation
Mammogram
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

8. common complication of inadequate mx of scaphoid fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Patellar tendon tear; difficulty in extension
Mammogram
Nonunion and avascular necrosis; fx can block blood supply;

9. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Displaced ORIF ; nondisplaced sling immobilization
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
When urethral catherization is unsuccessful

10. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If any compressive symptoms eg. dysphagia
Brardycardia - HTN - resp depression

11. perioral numbness after parathyroidectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Study showed no adverse effect; but they are contraindicated for PVD
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

12. How to manage obesity
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
50%; tunneling between rectum or kin
CRPS
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

13. how ABI help dx of PVD
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Low anterior resection and radio; add chemo if node positive
Mammogram

14. painless testicular mass in young male
Dm neuropathy; stocking glove pattern
Next best step surgery; not ultrasound
Malignancy until proven otherwise
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

15. anal sphincter tone
S2-S4
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;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

16. sudden onset of postoperative hyperglycemia when patient on TPN
Abd pain and tenderness; bloody diarrhoea or hematochezia
Supraglottic edema; low threshold for intubation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

17. management of hip fracture
Next best step surgery; not ultrasound
If patient ambulatory - surgery and pain control; if not nonop mx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Klinefelter syndrome; 50 fold increase;

18. scrotal trauma
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Next best step surgery; not ultrasound
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

19. mx of stress fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If patient ambulatory - surgery and pain control; if not nonop mx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

20. When do we see complications due to hypophosphatemia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
ACL injury

21. varicocele
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

22. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
When urethral catherization is unsuccessful
Retrograde ejaculation
Mammogram

23. swelling and tenderness in anterior part of knee
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Patellar tendon tear; difficulty in extension
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
Brardycardia - HTN - resp depression

24. SOB - confusion - petechial rash after trauma - fracture
Elderly and critically ill patients
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If patient ambulatory - surgery and pain control; if not nonop mx

25. How to differentiate ACL and meniscus injury
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
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
Even after ochiopexy risk of ochiopexy higher then general population
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

26. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Fx displace >1mm - nonunion during followup - osteonecrosis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If any compressive symptoms eg. dysphagia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

27. What is hydrocele?
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
Dumping syndrome; small and frequent meals; no simple sugar

28. severe pain in leg after MVC
50%; tunneling between rectum or kin
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
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

29. antibiotics of acute cholecystitis
Unilateral vocal cord paralysis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elderly and critically ill patients

30. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mammogram
Next best step surgery; not ultrasound
ACL injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

31. differential of ultrasound finding of breast mass
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

32. most common complication of acute cholecystitis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

33. menisci injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Twisting force with the foot fixed on the ground seen in football and basketball games;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
CRPS

34. inhalation of hot air - steam - smoke in burn victim
Patellar tendon tear; difficulty in extension
Supraglottic edema; low threshold for intubation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

35. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
10-12 months

36. suprapubic catheterization
When urethral catherization is unsuccessful
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Tendons more likely

37. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Urethral stricture; pelvic of urethral trauma
If any compressive symptoms eg. dysphagia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

38. Why initial xrays are negative in scaphoid fx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

39. acalculus cholecystitis
Elderly and critically ill patients
L5 to S2
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

40. What is most common lung injury after blunt chest trauma?
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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

41. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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 any compressive symptoms eg. dysphagia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

42. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
L5 to S2
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

43. How to confirm dx of compartment syndrom
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Next best step surgery; not ultrasound

44. ct scan; cystic lesion in head of pancreas; next step
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Meniscus injury; medial most common; pain/swelling; popping sensation

45. when scaphoid fx patient needs to be referred to orthopedic
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Fx displace >1mm - nonunion during followup - osteonecrosis
50%; tunneling between rectum or kin

46. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

47. varicose veins with ulcer - bleeding and thrombophlebitits
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Saline and silicone

48. surgery for acute cholecystities
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
24-48 hours of supportive therapy followed by cholecystectomy
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

49. Patient underwent CABG; postoperatively drowsy. most likely cause?
Headache - ataxia - bulbar dysfunction
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
Low anterior resection and radio; add chemo if node positive
Epi and chest compressio for prolong period of time; atropine is given after epi;

50. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
L5 to S2
SAH due to post communicating artery aneurysm;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Epi and chest compressio for prolong period of time; atropine is given after epi;