Test your basic knowledge |

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. popping sensation; rapid onset of knee effusion. athelet
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
ACL injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

2. What types of breast implants are available
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone
Malignancy until proven otherwise

3. lacerated wound in palmer surface of hand. what structure is injured?
Ispilateral hypoglossal nerve injury
Tendons more likely
Displaced ORIF ; nondisplaced sling immobilization
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

4. recurrent laryngeal nerve injury
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 any compressive symptoms eg. dysphagia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Unilateral vocal cord paralysis

5. ct scan; cystic lesion in head of pancreas; next step
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

6. stress fx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Seminomas
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

7. severe pain in leg after MVC
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;
Unilateral vocal cord paralysis
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

8. aspiration of breast cyst is bloody
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
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mammogram

9. What are the common injuries from lightning?
Increased size during the day and valsalva means it is communicated with peritoneal cavity
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

10. When to do surgery in undesceneded testis?
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

11. diarrhoea 4-5 days after cholecystectomy
If patient ambulatory - surgery and pain control; if not nonop mx
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
Study showed no adverse effect; but they are contraindicated for PVD
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

12. What time frame required for bone remodeling
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
15-40%; self limiting;doesn't require tx
10-12 months
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

13. cremasteric reflex test?
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

14. How to evaluate painless testicular swelling suspicious for cancer
Klinefelter syndrome; 50 fold increase;
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

15. transrectal prostate biopsy
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

16. complication displaced or communited distal radial fx
Elderly and critically ill patients
Nonunion and avascular necrosis; fx can block blood supply;
Carpal tunnel syndrom
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

17. types of hip fracture
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
4-6 weeks for noncontact sports and longer time for contact sports
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

18. pregnant patient with asymptomatic gall stones
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
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
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

19. clavicle fx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Displaced ORIF ; nondisplaced sling immobilization
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

20. contraindication of urethral catheterization
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Retrograde ejaculation
Klinefelter syndrome; 50 fold increase;
Urethral stricture; pelvic of urethral trauma

21. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
If patient ambulatory - surgery and pain control; if not nonop mx
Meniscus injury; medial most common; pain/swelling; popping sensation
Check ET tube placement if correct needle decompresion
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

22. How mcmurray manuver perform
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

23. When do we see complications due to hypophosphatemia
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;
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
Study showed no adverse effect; but they are contraindicated for PVD

24. How to dx ACL tear?
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

25. swelling and tenderness in anterior part of knee
If patient ambulatory - surgery and pain control; if not nonop mx
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
Patellar tendon tear; difficulty in extension
MAT; medial meniscus injury; ACL and Tibial colateral ligament

26. How to confirm achiles tendon rupture
Subphrenic abscess or other abdominal abscesses; order US or CT
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Check ET tube placement if correct needle decompresion

27. Why initial xrays are negative in scaphoid fx
24-48 hours of supportive therapy followed by cholecystectomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dm neuropathy; stocking glove pattern
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

28. 3 mo with groin bulge; bulge appears when child cries
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Even after ochiopexy risk of ochiopexy higher then general population
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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;

29. varicocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cystic scrotal fluid collection between parietal and visceral layers of testis
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. What is hydrocele?
Dm neuropathy; stocking glove pattern
ACL injury
Cystic scrotal fluid collection between parietal and visceral layers of testis
If any compressive symptoms eg. dysphagia

31. What is terrible triad
Ispilateral hypoglossal nerve injury
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

32. What is cushing's triad
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Saline and silicone
Brardycardia - HTN - resp depression

33. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months
Subphrenic abscess or other abdominal abscesses; order US or CT

34. What is the contraindication of hyperventilation in inc ICP
Compression stocking - weight reduction - leg elevation
Strok and traumatic brain injury
Unilateral vocal cord paralysis
Malignancy until proven otherwise

35. painless testicular mass in young male
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
Malignancy until proven otherwise
Strok and traumatic brain injury

36. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Urethral stricture; pelvic of urethral trauma
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

37. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
Nonunion and avascular necrosis; fx can block blood supply;

38. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
Retrograde ejaculation

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Unilateral vocal cord paralysis
24-48 hours of supportive therapy followed by cholecystectomy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

40. management of stone 8-10mm
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If any compressive symptoms eg. dysphagia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

41. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Urethral stricture; pelvic of urethral trauma
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;
50%; tunneling between rectum or kin

42. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Tendons more likely
Dm neuropathy; stocking glove pattern

43. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Less than 5mm
S2-S4

44. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Tendons more likely
CRPS

45. how ABI help dx of PVD
Sphincter sparing surgery (local resection) - abdomnio perineal resection
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pure motor stroke; limited neurological dysfunction
Seminomas

46. scrotal trauma
Next best step surgery; not ultrasound
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Urethral stricture; pelvic of urethral trauma
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

47. managment of animal bite in hands
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
Headache - ataxia - bulbar dysfunction
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;
Tendons more likely

48. SOB - confusion - petechial rash after trauma - fracture
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If any compressive symptoms eg. dysphagia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Displaced ORIF ; nondisplaced sling immobilization

49. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4-6 weeks for noncontact sports and longer time for contact sports
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

50. Valgus and Varus tests
Cystic scrotal fluid collection between parietal and visceral layers of testis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Meniscus injury; medial most common; pain/swelling; popping sensation
50%; tunneling between rectum or kin