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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. swelling and tenderness in anterior part of knee
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension
Headache - ataxia - bulbar dysfunction
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

2. What is most common lung injury after blunt chest 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
24-48 hours of supportive therapy followed by cholecystectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

3. What is hydrocele?
24-48 hours of supportive therapy followed by cholecystectomy
Cystic scrotal fluid collection between parietal and visceral layers of testis
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Patellar tendon tear; difficulty in extension

4. dorsiflexion and planter flexion
Strok and traumatic brain injury
Less than 5mm
L5 to S2
Dm neuropathy; stocking glove pattern

5. complications of TPN
Headache - ataxia - bulbar dysfunction
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

6. characteristics of ureteral stone?
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation
If any compressive symptoms eg. dysphagia

7. types of hip fracture
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Meniscus injury; medial most common; pain/swelling; popping sensation

8. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Twisting force with the foot fixed on the ground seen in football and basketball games;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Mammogram

9. anal sphincter tone
S2-S4
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

10. What is the contraindication of hyperventilation in inc ICP
CRPS
Strok and traumatic brain injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

11. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Headache - ataxia - bulbar dysfunction
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

12. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Headache - ataxia - bulbar dysfunction
If patient ambulatory - surgery and pain control; if not nonop mx

13. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Urethral stricture; pelvic of urethral trauma
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
When urethral catherization is unsuccessful

14. Valgus and Varus tests
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

15. recurrent laryngeal nerve injury
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis
Dm neuropathy; stocking glove pattern
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

16. Why right varicocele is more concerning?

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17. Why initial xrays are negative in scaphoid fx
Saline and silicone
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
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
Amoxicillin-clavulanate

18. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
SAH due to post communicating artery aneurysm;
Next best step surgery; not ultrasound
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

19. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Compression stocking - weight reduction - leg elevation
Saline and silicone
24-48 hours of supportive therapy followed by cholecystectomy

21. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;

22. management of gunshot wound
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Carpal tunnel syndrom
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

23. aspiration of breast cyst is bloody
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Mammogram
Nonunion and avascular necrosis; fx can block blood supply;

24. How mcmurray manuver perform
Ispilateral hypoglossal nerve injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Meniscus injury; medial most common; pain/swelling; popping sensation
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
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

26. diarrhoea after gastric bypass
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Malignancy until proven otherwise
Dumping syndrome; small and frequent meals; no simple sugar
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

27. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Next best step surgery; not ultrasound
Even after ochiopexy risk of ochiopexy higher then general population
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

28. complication displaced or communited distal radial fx
If any compressive symptoms eg. dysphagia
Carpal tunnel syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Displaced ORIF ; nondisplaced sling immobilization

29. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
L5 to S2
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Supraglottic edema; low threshold for intubation

30. What time frame required for bone remodeling
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
10-12 months
Next best step surgery; not ultrasound
Even after ochiopexy risk of ochiopexy higher then general population

31. 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
Dm neuropathy; stocking glove pattern
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If any compressive symptoms eg. dysphagia

32. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Less than 5mm
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

33. Incidence of AF in CABG patient

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34. What types of breast implants are available
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Saline and silicone

35. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dumping syndrome; small and frequent meals; no simple sugar

36. When to do surgery in undesceneded testis?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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

37. When do we see complications due to hypophosphatemia
Low anterior resection and radio; add chemo if node positive
Displaced ORIF ; nondisplaced sling immobilization
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;
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;

38. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Urethral stricture; pelvic of urethral trauma
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. Dupuytren contracture
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Progressive fibrosis of palmar fascia. etiololgy not known;
L5 to S2
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

40. suprapubic catheterization
When urethral catherization is unsuccessful
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

41. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
CRPS

42. lacunar stroke
Ispilateral hypoglossal nerve injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Pure motor stroke; limited neurological dysfunction

43. conservative Tx of varicose veins
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation
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

44. What are the common injuries from lightning?
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

45. popping sensation; rapid onset of knee effusion. athelet
Mammogram
ACL injury
Compression stocking - weight reduction - leg elevation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

46. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

47. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Tendons more likely

48. Why varicocele more common in the left side
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
When urethral catherization is unsuccessful

49. first step for evaluation of testicular swelling
Less than 5mm
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
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

50. differential of ultrasound finding of breast mass
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
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
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