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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 perform lachman test
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;
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;
ACL injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

2. What is the strongest risk factor for male breast cancer
Less than 5mm
Klinefelter syndrome; 50 fold increase;
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Next best step surgery; not ultrasound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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;

4. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

5. scrotal trauma
Supraglottic edema; low threshold for intubation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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

6. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Dm neuropathy; stocking glove pattern
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

7. when patient with severe lung disease have C02 retention
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

8. tx distal rectal ca
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

9. Why ruq calcificaion is concerning
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Twisting force with the foot fixed on the ground seen in football and basketball games;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

10. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
ACL injury
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

11. dorsiflexion and planter flexion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elderly and critically ill patients
L5 to S2
Cystic scrotal fluid collection between parietal and visceral layers of testis

12. 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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

13. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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

14. diarrhoea 4-5 days after cholecystectomy
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

15. first line of management of PVD
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Supraglottic edema; low threshold for intubation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

16. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

17. Patient underwent CABG; postoperatively drowsy. most likely cause?
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Supraglottic edema; low threshold for intubation

18. Tx of pulmonary contusion
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Ampicillin sublactum - pipercillin - ceftriaxone and metro
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

19. swelling and tenderness in anterior part of knee
Patellar tendon tear; difficulty in extension
Subphrenic abscess or other abdominal abscesses; order US or CT
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

20. Tx of proximal non metastatic rectal ca
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;
15-40%; self limiting;doesn't require tx
Pure motor stroke; limited neurological dysfunction
Low anterior resection and radio; add chemo if node positive

21. Incidence of AF in CABG patient

22. acalculus cholecystitis
Elderly and critically ill patients
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pure motor stroke; limited neurological dysfunction

23. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

25. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
15-40%; self limiting;doesn't require tx
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
Nonunion and avascular necrosis; fx can block blood supply;

26. lacerated wound in palmer surface of hand. what structure is injured?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Tendons more likely
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
10-12 months

27. lacunar stroke
When urethral catherization is unsuccessful
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
Pure motor stroke; limited neurological dysfunction
Less than 5mm

28. How to evaluate painless testicular swelling suspicious for cancer
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
ACL injury
Mammogram

29. cremasteric reflex test?
Patellar tendon tear; difficulty in extension
Less than 5mm
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Ispilateral hypoglossal nerve injury

30. ipsilateral deviation of tongue upon protrusion
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Ispilateral hypoglossal nerve injury
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;

31. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
SAH due to post communicating artery aneurysm;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

32. Indication for bariatric surgery in obese patients
Tendons more likely
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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 patient ambulatory - surgery and pain control; if not nonop mx

33. How mcmurray manuver perform
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check ET tube placement if correct needle decompresion
Dm neuropathy; stocking glove pattern

34. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pure motor stroke; limited neurological dysfunction
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dumping syndrome; small and frequent meals; no simple sugar

35. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

36. Most common of sudden death due to steering wheel injury
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

37. ct scan; cystic lesion in head of pancreas; next step
When urethral catherization is unsuccessful
Supraglottic edema; low threshold for intubation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

38. stress fx
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
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

39. mx of stress fx
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
Elevated non seminomas
When urethral catherization is unsuccessful

40. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
CRPS
Klinefelter syndrome; 50 fold increase;

41. SOB - confusion - petechial rash after trauma - fracture
4-6 weeks for noncontact sports and longer time for contact sports
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

42. what size of ureteral stone for non op mx
Tendons more likely
Twisting force with the foot fixed on the ground seen in football and basketball games;
Subphrenic abscess or other abdominal abscesses; order US or CT
Less than 5mm

43. prostate enlarged - nontender - no nodularity - elevated PSA
Urethral stricture; pelvic of urethral trauma
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Elevated non seminomas
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;

44. Valgus and Varus tests
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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. antibiotics of acute cholecystitis
Carpal tunnel syndrom
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Next best step surgery; not ultrasound

46. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Compression stocking - weight reduction - leg elevation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Dumping syndrome; small and frequent meals; no simple sugar

47. pregnant patient with asymptomatic gall stones
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Cystic scrotal fluid collection between parietal and visceral layers of testis

48. acute colonic ischemia
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
Compression stocking - weight reduction - leg elevation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Abd pain and tenderness; bloody diarrhoea or hematochezia

49. DD of acute scrotal pain
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

50. managment of animal bite in hands
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;
Pure motor stroke; limited neurological dysfunction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Saline and silicone