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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. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Next best step surgery; not ultrasound
50%; tunneling between rectum or kin
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

2. management of nondisplaced scaphoid fx
Supraglottic edema; low threshold for intubation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Fx displace >1mm - nonunion during followup - osteonecrosis

3. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Carpal tunnel syndrom

4. management of hip fracture
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
4-6 weeks for noncontact sports and longer time for contact sports
If patient ambulatory - surgery and pain control; if not nonop mx

5. 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
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
Low anterior resection and radio; add chemo if node positive

6. anal sphincter tone
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
S2-S4

7. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Retrograde ejaculation
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Urethral stricture; pelvic of urethral trauma

8. when patient with severe lung disease have C02 retention
L5 to S2
Klinefelter syndrome; 50 fold increase;
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

9. Most common of sudden death due to steering wheel injury
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

10. clavicle 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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Displaced ORIF ; nondisplaced sling immobilization

11. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

12. mangement of localized lymphadenopathy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Headache - ataxia - bulbar dysfunction
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

13. Tx of proximal non metastatic rectal ca
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Retrograde ejaculation
4-6 weeks for noncontact sports and longer time for contact sports
Low anterior resection and radio; add chemo if node positive

14. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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
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

15. menisci injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Twisting force with the foot fixed on the ground seen in football and basketball games;
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

16. midline neck swelling moves with protrusion of tongue
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

17. complications of TPN
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
L5 to S2
Dm neuropathy; stocking glove pattern

18. Complications of breast impant
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

19. sudden onset of postoperative hyperglycemia when patient on TPN
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

20. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ispilateral hypoglossal nerve injury
Tendons more likely
When urethral catherization is unsuccessful

21. What is hungry bone syndrome?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

22. surgery for acute cholecystities
Carpal tunnel syndrom
24-48 hours of supportive therapy followed by cholecystectomy
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elderly and critically ill patients

23. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Brardycardia - HTN - resp depression

24. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Retrograde ejaculation
Check ET tube placement if correct needle decompresion

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Displaced ORIF ; nondisplaced sling immobilization
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Even after ochiopexy risk of ochiopexy higher then general population

26. How to evaluate painless testicular swelling suspicious for cancer
Subphrenic abscess or other abdominal abscesses; order US or CT
Next best step surgery; not ultrasound
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

27. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Less than 5mm
SAH due to post communicating artery aneurysm;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

28. What is most common lung injury after blunt chest trauma?
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;
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
Retrograde ejaculation

29. 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
Brardycardia - HTN - resp depression
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

30. How mcmurray manuver perform
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Next best step surgery; not ultrasound

31. dorsiflexion and planter flexion
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
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization
S2-S4

32. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

33. What are the common injuries from lightning?
L5 to S2
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

34. painless testicular mass in young male
Compression stocking - weight reduction - leg elevation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Malignancy until proven otherwise
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

35. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

36. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Pure motor stroke; limited neurological dysfunction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

37. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Pure motor stroke; limited neurological dysfunction
Saline and silicone
Progressive fibrosis of palmar fascia. etiololgy not known;

38. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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. first step for evaluation of testicular swelling
SAH due to post communicating artery aneurysm;
Amoxicillin-clavulanate
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

40. What is prehn sign?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Mammogram

41. most frequent complication of TURP
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If patient ambulatory - surgery and pain control; if not nonop mx
Retrograde ejaculation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

42. acalculus cholecystitis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elderly and critically ill patients
Fx displace >1mm - nonunion during followup - osteonecrosis
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

43. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Compression stocking - weight reduction - leg elevation
Retrograde ejaculation
Nonunion and avascular necrosis; fx can block blood supply;

44. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Seminomas
Unilateral vocal cord paralysis

45. What types of breast implants are available
Epi and chest compressio for prolong period of time; atropine is given after epi;
Study showed no adverse effect; but they are contraindicated for PVD
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Saline and silicone

46. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
When urethral catherization is unsuccessful
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

47. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Meniscus injury; medial most common; pain/swelling; popping sensation

48. characteristics of ureteral stone?
Nonunion and avascular necrosis; fx can block blood supply;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
15-40%; self limiting;doesn't require tx

49. cremasteric reflex
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Mammogram
Carpal tunnel syndrom

50. several knee pain after being tackled in football game
Seminomas
CRPS
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)