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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. inhalation of hot air - steam - smoke in burn victim
Pure motor stroke; limited neurological dysfunction
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Supraglottic edema; low threshold for intubation

2. How to differentiate communicative and non-communicative hydrocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

3. swelling and tenderness in anterior part of knee
Progressive fibrosis of palmar fascia. etiololgy not known;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Elderly and critically ill patients
Patellar tendon tear; difficulty in extension

4. Why varicocele more common in the left side
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;
Mammogram
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Progressive fibrosis of palmar fascia. etiololgy not known;

5. when patient with severe lung disease have C02 retention
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
Even after ochiopexy risk of ochiopexy higher then general population
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

6. tx distal rectal ca
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;
Sphincter sparing surgery (local resection) - abdomnio perineal resection

7. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Subphrenic abscess or other abdominal abscesses; order US or CT
CRPS
Meniscus injury; medial most common; pain/swelling; popping sensation
24-48 hours of supportive therapy followed by cholecystectomy

8. Why right varicocele is more concerning?

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9. common complication of inadequate mx of scaphoid fx
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Nonunion and avascular necrosis; fx can block blood supply;
Low anterior resection and radio; add chemo if node positive

10. What percent of anal abscess deveolop fisutula
If any compressive symptoms eg. dysphagia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
50%; tunneling between rectum or kin

11. aspiration of breast cyst is bloody
Supraglottic edema; low threshold for intubation
Mammogram
Saline and silicone
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

12. beta HCG
50%; tunneling between rectum or kin
Seminomas
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
Elevated non seminomas

13. What is the contraindication of hyperventilation in inc ICP
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;
Fx displace >1mm - nonunion during followup - osteonecrosis
Strok and traumatic brain injury
Ispilateral hypoglossal nerve injury

14. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
If patient ambulatory - surgery and pain control; if not nonop mx

15. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Brardycardia - HTN - resp depression
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

16. What is terrible triad
Headache - ataxia - bulbar dysfunction
MAT; medial meniscus injury; ACL and Tibial colateral ligament
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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

17. severe pain in leg after MVC
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

18. anal sphincter tone
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Klinefelter syndrome; 50 fold increase;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
S2-S4

19. How to confirm achiles tendon rupture
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

20. sudden onset of postoperative hyperglycemia when patient on TPN
Elevated non seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

21. complication displaced or communited distal radial fx
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Carpal tunnel syndrom
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Next best step surgery; not ultrasound

22. lacunar stroke
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
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;
Pure motor stroke; limited neurological dysfunction

23. mx of stress fx
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
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

24. Valgus and Varus tests
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fx displace >1mm - nonunion during followup - osteonecrosis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

25. characteristics of ureteral stone?
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Ampicillin sublactum - pipercillin - ceftriaxone and metro

26. 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)
50%; tunneling between rectum or kin
Seminomas
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

27. scrotal 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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Next best step surgery; not ultrasound

28. What types of breast implants are available
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Saline and silicone

29. Why ruq calcificaion is concerning
Compression stocking - weight reduction - leg elevation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If patient ambulatory - surgery and pain control; if not nonop mx
Less than 5mm

30. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
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;
Study showed no adverse effect; but they are contraindicated for PVD
Ampicillin sublactum - pipercillin - ceftriaxone and metro

31. xray finding of stress fx after 3-4w
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Mammogram
L5 to S2
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

32. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

33. Patient underwent CABG; postoperatively drowsy. most likely cause?
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

34. menisci injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Next best step surgery; not ultrasound
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

35. When to do surgery in undesceneded testis?
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Meniscus injury; medial most common; pain/swelling; popping sensation
Headache - ataxia - bulbar dysfunction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

36. differential of ultrasound finding of breast mass
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

37. conservative Tx of varicose veins
24-48 hours of supportive therapy followed by cholecystectomy
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful
Compression stocking - weight reduction - leg elevation

38. midline neck swelling moves with protrusion of tongue
Less than 5mm
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before 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

39. 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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

40. SOB - confusion - petechial rash after trauma - fracture
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
CRPS

41. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dumping syndrome; small and frequent meals; no simple sugar
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

42. management of stone 8-10mm
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Next best step surgery; not ultrasound

43. management of gunshot wound
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dm neuropathy; stocking glove pattern
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

44. stress fx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
L5 to S2
Unilateral vocal cord paralysis

45. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Seminomas
Dm neuropathy; stocking glove pattern
Cystic scrotal fluid collection between parietal and visceral layers of testis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

46. Incidence of AF in CABG patient

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47. types of hip fracture
Next best step surgery; not ultrasound
Cystic scrotal fluid collection between parietal and visceral layers of testis
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

48. cremasteric reflex test?
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
S2-S4

49. What is the strongest risk factor for male breast cancer
Next best step surgery; not ultrasound
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Klinefelter syndrome; 50 fold increase;

50. Why initial xrays are negative in scaphoid fx
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
S2-S4
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Unilateral vocal cord paralysis