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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 dx ACL tear?
ACL injury
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Retrograde ejaculation

2. Can we use beta blocker for pvd?
When urethral catherization is unsuccessful
Dumping syndrome; small and frequent meals; no simple sugar
Study showed no adverse effect; but they are contraindicated for PVD
Seminomas

3. lacerated wound in palmer surface of hand. what structure is injured?
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Tendons more likely
Cystic scrotal fluid collection between parietal and visceral layers of testis

4. first line of management of PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

5. when patient with severe lung disease have C02 retention
Saline and silicone
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Seminomas

6. cremasteric reflex test?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

7. scrotal trauma
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
If any compressive symptoms eg. dysphagia
Check ET tube placement if correct needle decompresion

8. prostate enlarged - nontender - no nodularity - elevated PSA
Strok and traumatic brain injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

9. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Urethral stricture; pelvic of urethral trauma
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Pure motor stroke; limited neurological dysfunction

10. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Malignancy until proven otherwise
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

11. ct scan; cystic lesion in head of pancreas; next step
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dumping syndrome; small and frequent meals; no simple sugar
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

12. What are the common injuries from lightning?
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

13. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
10-12 months
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dumping syndrome; small and frequent meals; no simple sugar
50%; tunneling between rectum or kin

14. What is most common lung injury after blunt chest trauma?
Low anterior resection and radio; add chemo if node positive
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
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;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

15. When to do surgery in undesceneded testis?
Epi and chest compressio for prolong period of time; atropine is given after epi;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
Strok and traumatic brain injury

16. most common complication of acute cholecystitis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

17. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Subphrenic abscess or other abdominal abscesses; order US or CT

18. transrectal prostate biopsy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

19. mangement of localized lymphadenopathy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Study showed no adverse effect; but they are contraindicated for PVD
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
When urethral catherization is unsuccessful

20. most frequent complication of TURP
Dm neuropathy; stocking glove pattern
Elevated non seminomas
Retrograde ejaculation
Less than 5mm

21. management of hip fracture
Nonunion and avascular necrosis; fx can block blood supply;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If patient ambulatory - surgery and pain control; if not nonop mx
Strok and traumatic brain injury

22. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Meniscus injury; medial most common; pain/swelling; popping sensation
Next best step surgery; not ultrasound
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

23. how hyperventilation lowers ICP
Meniscus injury; medial most common; pain/swelling; popping sensation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

24. swelling and tenderness in anterior part of knee
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Patellar tendon tear; difficulty in extension
Strok and traumatic brain injury
Subphrenic abscess or other abdominal abscesses; order US or CT

25. Most common of sudden death due to steering wheel injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Compression stocking - weight reduction - leg elevation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Subphrenic abscess or other abdominal abscesses; order US or CT

26. Dupuytren contracture
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
Less than 5mm
Progressive fibrosis of palmar fascia. etiololgy not known;
Dumping syndrome; small and frequent meals; no simple sugar

27. cremasteric reflex
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
When urethral catherization is unsuccessful
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

28. acalculus cholecystitis
Elderly and critically ill patients
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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

29. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Headache - ataxia - bulbar dysfunction

30. How to confirm achiles tendon rupture
Mammogram
Malignancy until proven otherwise
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

31. when scaphoid fx patient needs to be referred to orthopedic
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Fx displace >1mm - nonunion during followup - osteonecrosis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

32. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Amoxicillin-clavulanate
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Compression stocking - weight reduction - leg elevation

33. indication of ursodeoxycholic acid
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Compression stocking - weight reduction - leg elevation
MAT; medial meniscus injury; ACL and Tibial colateral ligament

34. SAH due to posterior inferior cerebellar aneurysm
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Headache - ataxia - bulbar dysfunction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

35. Valgus and Varus tests
Pure motor stroke; limited neurological dysfunction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

36. popping sensation; rapid onset of knee effusion. athelet
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
ACL injury
L5 to S2
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

37. diarrhoea after gastric bypass
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dumping syndrome; small and frequent meals; no simple sugar

38. What percent of anal abscess deveolop fisutula
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
50%; tunneling between rectum or kin
10-12 months
4-6 weeks for noncontact sports and longer time for contact sports

39. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Ispilateral hypoglossal nerve injury

40. what size of ureteral stone for non op mx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Less than 5mm
ACL injury
24-48 hours of supportive therapy followed by cholecystectomy

41. SOB - confusion - petechial rash after trauma - fracture
Nonunion and avascular necrosis; fx can block blood supply;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

42. When do we see complications due to hypophosphatemia
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;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

43. beta hcg and AFP
Elevated non seminomas
Headache - ataxia - bulbar dysfunction
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Study showed no adverse effect; but they are contraindicated for PVD

44. What is the contraindication of hyperventilation in inc ICP
Twisting force with the foot fixed on the ground seen in football and basketball games;
Strok and traumatic brain injury
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
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

45. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
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
Dm neuropathy; stocking glove pattern
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

46. beta HCG
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Seminomas

47. diarrhoea 4-5 days after cholecystectomy
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Brardycardia - HTN - resp depression
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dumping syndrome; small and frequent meals; no simple sugar

48. Why right varicocele is more concerning?

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49. how ABI help dx of PVD
SAH due to post communicating artery aneurysm;
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

50. sudden onset of postoperative hyperglycemia when patient on TPN
Patellar tendon tear; difficulty in extension
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
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
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;