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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. SAH due to posterior inferior cerebellar aneurysm
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Headache - ataxia - bulbar dysfunction
Dm neuropathy; stocking glove pattern
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

2. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Progressive fibrosis of palmar fascia. etiololgy not known;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

3. painless testicular mass in young male
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If patient ambulatory - surgery and pain control; if not nonop mx
Malignancy until proven otherwise

4. dorsiflexion and planter flexion
L5 to S2
Klinefelter syndrome; 50 fold increase;
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

5. how ABI help dx of PVD
50%; tunneling between rectum or kin
Pure motor stroke; limited neurological dysfunction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Elevated non seminomas

6. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Strok and traumatic brain injury

7. transrectal prostate biopsy
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
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
Less than 5mm

8. popping sensation; rapid onset of knee effusion. athelet
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Pure motor stroke; limited neurological dysfunction
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ACL injury

9. xray finding of stress fx after 3-4w
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

10. indication of ursodeoxycholic acid
L5 to S2
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

11. cremasteric reflex test?
Meniscus injury; medial most common; pain/swelling; popping sensation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Next best step surgery; not ultrasound

12. What is most common lung injury after blunt chest trauma?
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

13. complication displaced or communited distal radial fx
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
10-12 months
Carpal tunnel syndrom

14. Tx of proximal non metastatic rectal ca
SAH due to post communicating artery aneurysm;
Compression stocking - weight reduction - leg elevation
Low anterior resection and radio; add chemo if node positive
Even after ochiopexy risk of ochiopexy higher then general population

15. Can we use beta blocker for pvd?
Malignancy until proven otherwise
Next best step surgery; not ultrasound
ACL injury
Study showed no adverse effect; but they are contraindicated for PVD

16. What are the common injuries from lightning?
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Brardycardia - HTN - resp depression

17. diarrhoea after gastric bypass
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Dumping syndrome; small and frequent meals; no simple sugar
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

18. What is hungry bone syndrome?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Progressive fibrosis of palmar fascia. etiololgy not known;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

19. 27 yo with scrotal mass; warm tender testes feel like bag of worms
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Supraglottic edema; low threshold for intubation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

20. Complications of breast impant
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

21. mx of stress fx
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Low anterior resection and radio; add chemo if node positive
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

22. beta hcg and AFP
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Amoxicillin-clavulanate
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Elevated non seminomas

23. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

24. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
CRPS
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

25. anal sphincter tone
S2-S4
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
4-6 weeks for noncontact sports and longer time for contact sports
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

26. Valgus and Varus tests
Low anterior resection and radio; add chemo if node positive
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Unilateral vocal cord paralysis

27. Why ruq calcificaion is concerning
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
Check ET tube placement if correct needle decompresion
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Seminomas

28. differential of ultrasound finding of breast mass
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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
Supraglottic edema; low threshold for intubation

29. What is terrible triad
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
CRPS
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Patellar tendon tear; difficulty in extension

30. When to stop raloxifene before surgery
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Check ET tube placement if correct needle decompresion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

31. prostate enlarged - nontender - no nodularity - elevated PSA
SAH due to post communicating artery aneurysm;
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Tendons more likely

32. When to do surgery in undesceneded testis?
Carpal tunnel syndrom
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

33. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

34. 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;
If any compressive symptoms eg. dysphagia
Dm neuropathy; stocking glove pattern
Progressive fibrosis of palmar fascia. etiololgy not known;

35. Incidence of AF in CABG patient

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36. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
15-40%; self limiting;doesn't require tx
S2-S4
Twisting force with the foot fixed on the ground seen in football and basketball games;

37. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Retrograde ejaculation
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

38. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Saline and silicone
Dm neuropathy; stocking glove pattern
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
Even after ochiopexy risk of ochiopexy higher then general population

39. Tx of pulmonary contusion
Displaced ORIF ; nondisplaced sling immobilization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

40. scrotal trauma
Saline and silicone
Next best step surgery; not ultrasound
Headache - ataxia - bulbar dysfunction
Klinefelter syndrome; 50 fold increase;

41. midline neck swelling moves with protrusion of tongue
Brardycardia - HTN - resp depression
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;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Abd pain and tenderness; bloody diarrhoea or hematochezia

42. first step for evaluation of testicular swelling
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
Patellar tendon tear; difficulty in extension
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

43. dumping syndrome after gastrectomy
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Supraglottic edema; low threshold for intubation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
24-48 hours of supportive therapy followed by cholecystectomy

44. mangement of localized lymphadenopathy
4-6 weeks for noncontact sports and longer time for contact sports
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

45. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Meniscus injury; medial most common; pain/swelling; popping sensation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

46. swelling and tenderness in anterior part of knee
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Strok and traumatic brain injury
Mammogram
Patellar tendon tear; difficulty in extension

47. aspiration of breast cyst is bloody
Mammogram
L5 to S2
MAT; medial meniscus injury; ACL and Tibial colateral ligament
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

48. most common complication of acute cholecystitis
L5 to S2
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Klinefelter syndrome; 50 fold increase;

49. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Pure motor stroke; limited neurological dysfunction
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

50. How to perform lachman test
15-40%; self limiting;doesn't require tx
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy