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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. popping sensation; rapid onset of knee effusion. athelet
Low anterior resection and radio; add chemo if node positive
ACL injury
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;

2. varicocele
If any compressive symptoms eg. dysphagia
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

3. cremasteric reflex
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Patellar tendon tear; difficulty in extension
Strok and traumatic brain injury

4. What is hydrocele?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Cystic scrotal fluid collection between parietal and visceral layers of testis
L5 to S2
CRPS

5. How mcmurray manuver perform
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
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

6. most frequent complication of TURP
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Retrograde ejaculation
When urethral catherization is unsuccessful

7. complications of TPN
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
Nonunion and avascular necrosis; fx can block blood supply;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Malignancy until proven otherwise

8. Tx of proximal non metastatic rectal ca
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
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Low anterior resection and radio; add chemo if node positive

9. Tx of pulmonary contusion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Progressive fibrosis of palmar fascia. etiololgy not known;
S2-S4
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

10. when scaphoid fx patient needs to be referred to orthopedic
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Fx displace >1mm - nonunion during followup - osteonecrosis
Mammogram
Dumping syndrome; small and frequent meals; no simple sugar

11. what size of ureteral stone for non op mx
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
Less than 5mm
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

12. Why right varicocele is more concerning?

13. Why ruq calcificaion is concerning
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Displaced ORIF ; nondisplaced sling immobilization

14. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Subphrenic abscess or other abdominal abscesses; order US or CT
Mammogram
Amoxicillin-clavulanate

15. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

16. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Elderly and critically ill patients
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;

17. lacerated wound in palmer surface of hand. what structure is injured?
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Elevated non seminomas
Tendons more likely

18. How to differentiate communicative and non-communicative hydrocele
Retrograde ejaculation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If patient ambulatory - surgery and pain control; if not nonop mx

19. diarrhoea 4-5 days after cholecystectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

20. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dm neuropathy; stocking glove pattern
Carpal tunnel syndrom

21. clavicle fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Displaced ORIF ; nondisplaced sling immobilization
Malignancy until proven otherwise
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

22. varicose veins with ulcer - bleeding and thrombophlebitits
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dumping syndrome; small and frequent meals; no simple sugar
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;

23. contraindication of urethral catheterization
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
Urethral stricture; pelvic of urethral trauma
4-6 weeks for noncontact sports and longer time for contact sports
SAH due to post communicating artery aneurysm;

24. indication of ursodeoxycholic acid
Unilateral vocal cord paralysis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

25. 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection

26. What types of breast implants are available
Saline and silicone
Pure motor stroke; limited neurological dysfunction
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

27. menisci injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Twisting force with the foot fixed on the ground seen in football and basketball games;

28. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

29. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
S2-S4
50%; tunneling between rectum or kin

30. What is the contraindication of hyperventilation in inc ICP
Headache - ataxia - bulbar dysfunction
Displaced ORIF ; nondisplaced sling immobilization
Strok and traumatic brain injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Ispilateral hypoglossal nerve injury
Elderly and critically ill patients

32. conservative Tx of varicose veins
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Compression stocking - weight reduction - leg elevation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

33. inhalation of hot air - steam - smoke in burn victim
Urethral stricture; pelvic of urethral trauma
50%; tunneling between rectum or kin
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Supraglottic edema; low threshold for intubation

34. SAH due to posterior inferior cerebellar aneurysm
Malignancy until proven otherwise
Progressive fibrosis of palmar fascia. etiololgy not known;
Pure motor stroke; limited neurological dysfunction
Headache - ataxia - bulbar dysfunction

35. How varicocele causes testicular atrophy
Mammogram
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Urethral stricture; pelvic of urethral trauma

36. What is cushing's triad
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Brardycardia - HTN - resp depression
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dumping syndrome; small and frequent meals; no simple sugar

37. Indication for bariatric surgery in obese patients
Nonunion and avascular necrosis; fx can block blood supply;
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Next best step surgery; not ultrasound

38. lacunar stroke
Ampicillin sublactum - pipercillin - ceftriaxone and metro
10-12 months
Pure motor stroke; limited neurological dysfunction
Carpal tunnel syndrom

39. Valgus and Varus tests
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Klinefelter syndrome; 50 fold increase;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

40. most common fx when falling on outsretched hand
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Amoxicillin-clavulanate
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

41. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
CRPS
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
Pure motor stroke; limited neurological dysfunction

42. transrectal prostate biopsy
Unilateral vocal cord paralysis
4-6 weeks for noncontact sports and longer time for contact sports
Less than 5mm
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

43. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Amoxicillin-clavulanate

44. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Displaced ORIF ; nondisplaced sling immobilization
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
Supraglottic edema; low threshold for intubation

45. tx distal rectal ca
15-40%; self limiting;doesn't require tx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

46. Complications of breast impant
15-40%; self limiting;doesn't require tx
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
4-6 weeks for noncontact sports and longer time for contact sports
Pure motor stroke; limited neurological dysfunction

47. painless testicular mass in young male
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Malignancy until proven otherwise
Ispilateral hypoglossal nerve injury

48. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
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
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation

49. severe pain in leg after MVC
Carpal tunnel syndrom
Saline and silicone
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

50. first step for evaluation of testicular swelling
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Seminomas
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins