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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 mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal 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
15-40%; self limiting;doesn't require tx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

2. How to differentiate ACL and meniscus injury
Study showed no adverse effect; but they are contraindicated for PVD
Unilateral vocal cord paralysis
Strok and traumatic brain injury
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. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dumping syndrome; small and frequent meals; no simple sugar
Subphrenic abscess or other abdominal abscesses; order US or CT

4. perioral numbness after parathyroidectomy
Study showed no adverse effect; but they are contraindicated for PVD
15-40%; self limiting;doesn't require tx
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

5. Dupuytren contracture
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 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
Saline and silicone
Progressive fibrosis of palmar fascia. etiololgy not known;

6. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Patellar tendon tear; difficulty in extension
Brardycardia - HTN - resp depression
MAT; medial meniscus injury; ACL and Tibial colateral ligament

7. What is the strongest risk factor for male breast cancer
Nonunion and avascular necrosis; fx can block blood supply;
Klinefelter syndrome; 50 fold increase;
Patellar tendon tear; difficulty in extension
Less than 5mm

8. clavicle fx
Pure motor stroke; limited neurological dysfunction
Displaced ORIF ; nondisplaced sling immobilization
15-40%; self limiting;doesn't require tx
Patellar tendon tear; difficulty in extension

9. management of hip fracture
Headache - ataxia - bulbar dysfunction
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

10. Why ruq calcificaion is concerning
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Study showed no adverse effect; but they are contraindicated for PVD
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

11. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
SAH due to post communicating artery aneurysm;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

12. How varicocele causes testicular atrophy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Ampicillin sublactum - pipercillin - ceftriaxone and metro

13. Why initial xrays are negative in scaphoid fx
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

14. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Seminomas
Unilateral vocal cord paralysis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

15. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check ET tube placement if correct needle decompresion

16. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Malignancy until proven otherwise
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

17. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Even after ochiopexy risk of ochiopexy higher then general population
S2-S4
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

18. Valgus and Varus tests
Unilateral vocal cord paralysis
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;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

19. dorsiflexion and planter flexion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Patellar tendon tear; difficulty in extension
L5 to S2
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

20. varicose veins with ulcer - bleeding and thrombophlebitits
SAH due to post communicating artery aneurysm;
Low anterior resection and radio; add chemo if node positive
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

21. contraindication of urethral catheterization
Mammogram
Abd pain and tenderness; bloody diarrhoea or hematochezia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Urethral stricture; pelvic of urethral trauma

22. Complications of breast impant
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elderly and critically ill patients
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

23. severe pain in leg after MVC
Urethral stricture; pelvic of urethral trauma
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

24. acalculus cholecystitis
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Check ET tube placement if correct needle decompresion
Elderly and critically ill patients
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

25. diarrhoea after gastric bypass
Strok and traumatic brain injury
Pure motor stroke; limited neurological dysfunction
Dumping syndrome; small and frequent meals; no simple sugar
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

26. What are the common injuries from lightning?
Check ET tube placement if correct needle decompresion
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

27. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Tendons more likely
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

28. What is hydrocele?
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Cystic scrotal fluid collection between parietal and visceral layers of testis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

29. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
50%; tunneling between rectum or kin

30. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dm neuropathy; stocking glove pattern
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Meniscus injury; medial most common; pain/swelling; popping sensation

31. How to evaluate painless testicular swelling suspicious for cancer
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Urethral stricture; pelvic of urethral trauma

32. dumping syndrome after gastrectomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

33. When do we see complications due to hypophosphatemia
Progressive fibrosis of palmar fascia. etiololgy not known;
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

34. What is hungry bone syndrome?
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

35. When to stop raloxifene before surgery
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Next best step surgery; not ultrasound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

36. diarrhoea 4-5 days after cholecystectomy
Patellar tendon tear; difficulty in extension
Urethral stricture; pelvic of urethral trauma
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

37. stress fx
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Strok and traumatic brain injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

38. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Even after ochiopexy risk of ochiopexy higher then general population

39. When to do surgery in undesceneded testis?
Carpal tunnel syndrom
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
Brardycardia - HTN - resp depression

40. SOB - confusion - petechial rash after trauma - fracture
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

41. How to perform lachman test
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

42. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

43. How to confirm achiles tendon rupture
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
10-12 months
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
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

44. ipsilateral deviation of tongue upon protrusion
L5 to S2
Ispilateral hypoglossal nerve injury
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

45. What is cushing's triad
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Brardycardia - HTN - resp depression
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

46. How to differentiate communicative and non-communicative hydrocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If any compressive symptoms eg. dysphagia

47. DD of acute scrotal pain
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Low anterior resection and radio; add chemo if node positive
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

48. mangement of localized lymphadenopathy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
L5 to S2
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sphincter sparing surgery (local resection) - abdomnio perineal resection

49. differential of ultrasound finding of breast mass
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Dm neuropathy; stocking glove pattern
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

50. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Saline and silicone