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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
S2-S4
CRPS
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased size during the day and valsalva means it is communicated with peritoneal cavity

2. Tx of proximal non metastatic rectal ca
15-40%; self limiting;doesn't require tx
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
Low anterior resection and radio; add chemo if node positive
4-6 weeks for noncontact sports and longer time for contact sports

3. cremasteric reflex test?
15-40%; self limiting;doesn't require tx
Even after ochiopexy risk of ochiopexy higher then general population
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

4. cremasteric reflex
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Dm neuropathy; stocking glove pattern
Study showed no adverse effect; but they are contraindicated for PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

5. 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
Strok and traumatic brain injury
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful

6. When patient can go back to sports after clavicle fx
Even after ochiopexy risk of ochiopexy higher then general population
4-6 weeks for noncontact sports and longer time for contact sports
50%; tunneling between rectum or kin
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

7. ipsilateral deviation of tongue upon protrusion
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;
CRPS
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
Ispilateral hypoglossal nerve injury

8. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

9. Incidence of AF in CABG patient

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10. How mcmurray manuver perform
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

11. most common complication of acute cholecystitis
Seminomas
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Amoxicillin-clavulanate

12. What is prehn sign?
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Seminomas

13. suprapubic catheterization
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
When urethral catherization is unsuccessful
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

14. SOB - confusion - petechial rash after trauma - fracture
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

15. surgery for acute cholecystities
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
24-48 hours of supportive therapy followed by cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population

16. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

17. How to manage obesity
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
S2-S4
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Malignancy until proven otherwise

18. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

19. diarrhoea 4-5 days after cholecystectomy
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
Dm neuropathy; stocking glove pattern
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

20. beta hcg and AFP
Elevated non seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Low anterior resection and radio; add chemo if node positive
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

21. What is cushing's triad
Mammogram
Brardycardia - HTN - resp depression
Even after ochiopexy risk of ochiopexy higher then general population
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

22. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
24-48 hours of supportive therapy followed by cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis

23. midline neck swelling moves with protrusion of tongue
Tendons more likely
Brardycardia - HTN - resp depression
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

24. How to evaluate painless testicular swelling suspicious for cancer
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Ispilateral hypoglossal nerve injury

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Carpal tunnel syndrom
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

26. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
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;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

27. ct scan; cystic lesion in head of pancreas; next step
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

28. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Even after ochiopexy risk of ochiopexy higher then general population
Mammogram
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;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

29. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mammogram
Meniscus injury; medial most common; pain/swelling; popping sensation

30. most common fx when falling on outsretched hand
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Twisting force with the foot fixed on the ground seen in football and basketball games;

31. inhalation of hot air - steam - smoke in burn victim
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
CRPS
Supraglottic edema; low threshold for intubation

32. aspiration of breast cyst is nonbloody
Next best step surgery; not ultrasound
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
50%; tunneling between rectum or kin
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

33. acute colonic ischemia
Tendons more likely
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;
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

34. Why ruq calcificaion is concerning
L5 to S2
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
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

35. dorsiflexion and planter flexion
L5 to S2
Strok and traumatic brain injury
If any compressive symptoms eg. dysphagia
Dm neuropathy; stocking glove pattern

36. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Progressive fibrosis of palmar fascia. etiololgy not known;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

37. when patient with severe lung disease have C02 retention
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
Displaced ORIF ; nondisplaced sling immobilization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

38. mangement of localized lymphadenopathy
Low anterior resection and radio; add chemo if node positive
Abd pain and tenderness; bloody diarrhoea or hematochezia
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Klinefelter syndrome; 50 fold increase;

39. What time frame required for bone remodeling
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Compression stocking - weight reduction - leg elevation
MAT; medial meniscus injury; ACL and Tibial colateral ligament
10-12 months

40. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
SAH due to post communicating artery aneurysm;
Dumping syndrome; small and frequent meals; no simple sugar
Headache - ataxia - bulbar dysfunction

41. How to confirm achiles tendon rupture
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

42. lacunar stroke
Brardycardia - HTN - resp depression
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Pure motor stroke; limited neurological dysfunction
Nonunion and avascular necrosis; fx can block blood supply;

43. When do we see complications due to hypophosphatemia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;
15-40%; self limiting;doesn't require tx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

44. Why varicocele more common in the left side
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
Low anterior resection and radio; add chemo if node positive
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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. what size of ureteral stone for non op mx
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Less than 5mm
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

46. 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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Klinefelter syndrome; 50 fold increase;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

47. When to do surgery in undesceneded testis?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Even after ochiopexy risk of ochiopexy higher then general population
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

48. lacerated wound in palmer surface of hand. what structure is injured?
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
Tendons more likely
Twisting force with the foot fixed on the ground seen in football and basketball games;
Dm neuropathy; stocking glove pattern

49. stress fx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

50. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
S2-S4
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;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction