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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. indication of ursodeoxycholic acid
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
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
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;
Study showed no adverse effect; but they are contraindicated for PVD

2. When goiter needs surgery
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Dumping syndrome; small and frequent meals; no simple sugar

3. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Nonunion and avascular necrosis; fx can block blood supply;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Less than 5mm

4. Complications of breast impant
Progressive fibrosis of palmar fascia. etiololgy not known;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

5. cremasteric reflex
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dm neuropathy; stocking glove pattern
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

6. ipsilateral deviation of tongue upon protrusion
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ispilateral hypoglossal nerve injury
ACL injury
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

7. What are the common injuries from lightning?
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Subphrenic abscess or other abdominal abscesses; order US or CT
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

8. conservative Tx of varicose veins
Dm neuropathy; stocking glove pattern
Pure motor stroke; limited neurological dysfunction
Compression stocking - weight reduction - leg elevation
Subphrenic abscess or other abdominal abscesses; order US or CT

9. transrectal prostate biopsy
Pure motor stroke; limited neurological dysfunction
Subphrenic abscess or other abdominal abscesses; order US or CT
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

10. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
15-40%; self limiting;doesn't require tx
Pure motor stroke; limited neurological dysfunction
Malignancy until proven otherwise

11. diarrhoea after gastric bypass
Dumping syndrome; small and frequent meals; no simple sugar
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

12. types of hip fracture
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

13. differential of ultrasound finding of breast mass
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If patient ambulatory - surgery and pain control; if not nonop mx

14. clavicle fx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Displaced ORIF ; nondisplaced sling immobilization
CRPS

15. How to confirm achiles tendon rupture
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Subphrenic abscess or other abdominal abscesses; order US or CT
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

16. dorsiflexion and planter flexion
L5 to S2
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
S2-S4
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

17. popping sensation; rapid onset of knee effusion. athelet
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Next best step surgery; not ultrasound

18. Tx of proximal non metastatic rectal ca
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Malignancy until proven otherwise
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Low anterior resection and radio; add chemo if node positive

19. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Strok and traumatic brain injury
Unilateral vocal cord paralysis

20. How to differentiate ACL and meniscus injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Displaced ORIF ; nondisplaced sling immobilization

21. How to manage a patient with asystole
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Epi and chest compressio for prolong period of time; atropine is given after epi;

22. management of stone 8-10mm
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elevated non seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

23. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
S2-S4
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

24. DD of acute scrotal pain
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Headache - ataxia - bulbar dysfunction

25. How to dx ACL tear?
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

26. Why initial xrays are negative in scaphoid fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

27. when scaphoid fx patient needs to be referred to orthopedic
Brardycardia - HTN - resp depression
Displaced ORIF ; nondisplaced sling immobilization
Fx displace >1mm - nonunion during followup - osteonecrosis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

28. What is the strongest risk factor for male breast cancer
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Klinefelter syndrome; 50 fold increase;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
When urethral catherization is unsuccessful

29. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dumping syndrome; small and frequent meals; no simple sugar
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;

30. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elderly and critically ill patients
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

31. Incidence of AF in CABG patient

32. dumping syndrome after gastrectomy
Ispilateral hypoglossal nerve injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

33. ct scan; cystic lesion in head of pancreas; next step
Twisting force with the foot fixed on the ground seen in football and basketball games;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
50%; tunneling between rectum or kin
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

34. most common fx when falling on outsretched hand
ACL injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

35. sudden onset of postoperative hyperglycemia when patient on TPN
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Study showed no adverse effect; but they are contraindicated for PVD
Cystic scrotal fluid collection between parietal and visceral layers of testis
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

36. Valgus and Varus tests
Elevated non seminomas
Nonunion and avascular necrosis; fx can block blood supply;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

37. What is terrible triad
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
50%; tunneling between rectum or kin
Malignancy until proven otherwise
MAT; medial meniscus injury; ACL and Tibial colateral ligament

38. most common complication of acute cholecystitis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Meniscus injury; medial most common; pain/swelling; popping sensation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

39. complication displaced or communited distal radial fx
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Carpal tunnel syndrom
Low anterior resection and radio; add chemo if node positive

40. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If patient ambulatory - surgery and pain control; if not nonop mx
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

41. perioral numbness after parathyroidectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
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;
Strok and traumatic brain injury

42. What is the complications of undescended testis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
L5 to S2
Even after ochiopexy risk of ochiopexy higher then general population
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

43. acalculus cholecystitis
Elderly and critically ill patients
24-48 hours of supportive therapy followed by cholecystectomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

44. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Nonunion and avascular necrosis; fx can block blood supply;
CRPS
Brardycardia - HTN - resp depression

45. characteristics of ureteral stone?
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Dm neuropathy; stocking glove pattern
Saline and silicone
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

46. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
CRPS
10-12 months
Twisting force with the foot fixed on the ground seen in football and basketball games;

47. How to confirm dx of compartment syndrom
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

48. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Ispilateral hypoglossal nerve injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Tendons more likely

49. Why varicocele more common in the left side
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

50. What is hydrocele?
Retrograde ejaculation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Cystic scrotal fluid collection between parietal and visceral layers of testis