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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. ct scan; cystic lesion in head of pancreas; next step
Klinefelter syndrome; 50 fold increase;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

2. tx distal rectal ca
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Sphincter sparing surgery (local resection) - abdomnio perineal resection

3. xray finding of stress fx after 3-4w
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
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

4. beta HCG
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Carpal tunnel syndrom
Seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

5. How to differentiate communicative and non-communicative hydrocele
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Unilateral vocal cord paralysis
Increased size during the day and valsalva means it is communicated with peritoneal cavity

6. managment of animal bite in hands
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;
Fx displace >1mm - nonunion during followup - osteonecrosis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

7. severe pain in leg after MVC
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

8. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Dm neuropathy; stocking glove pattern

9. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Ispilateral hypoglossal nerve injury
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
S2-S4

10. swelling and tenderness in anterior part of knee
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Patellar tendon tear; difficulty in extension
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

11. management of hip fracture
S2-S4
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If patient ambulatory - surgery and pain control; if not nonop mx

12. dorsiflexion and planter flexion
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
L5 to S2
24-48 hours of supportive therapy followed by cholecystectomy
Urethral stricture; pelvic of urethral trauma

13. What is cushing's triad
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
24-48 hours of supportive therapy followed by cholecystectomy

14. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Pure motor stroke; limited neurological dysfunction
Sphincter sparing surgery (local resection) - abdomnio perineal resection
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

15. How to differentiate ACL and meniscus injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

16. How to manage a patient with asystole
Carpal tunnel syndrom
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

17. Incidence of AF in CABG patient

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18. How to perform lachman test
Supraglottic edema; low threshold for intubation
S2-S4
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

19. complications of TPN
Check ET tube placement if correct needle decompresion
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

20. Complications of breast impant
Compression stocking - weight reduction - leg elevation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

21. what size of ureteral stone for non op mx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Less than 5mm
Even after ochiopexy risk of ochiopexy higher then general population
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

22. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevated non seminomas

23. conservative Tx of varicose veins
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Compression stocking - weight reduction - leg elevation
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

24. What is the strongest risk factor for male breast cancer
Less than 5mm
Displaced ORIF ; nondisplaced sling immobilization
Klinefelter syndrome; 50 fold increase;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

25. Most common of sudden death due to steering wheel injury
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
L5 to S2
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

26. management of stone 8-10mm
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Cystic scrotal fluid collection between parietal and visceral layers of testis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

27. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Fx displace >1mm - nonunion during followup - osteonecrosis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If patient ambulatory - surgery and pain control; if not nonop mx

28. indication of ursodeoxycholic acid
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

29. suprapubic catheterization
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Saline and silicone
When urethral catherization is unsuccessful
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

30. when scaphoid fx patient needs to be referred to orthopedic
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Fx displace >1mm - nonunion during followup - osteonecrosis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

31. inhalation of hot air - steam - smoke in burn victim
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Meniscus injury; medial most common; pain/swelling; popping sensation
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Supraglottic edema; low threshold for intubation

32. How to dx ACL tear?
Fx displace >1mm - nonunion during followup - osteonecrosis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

33. Valgus and Varus tests
Study showed no adverse effect; but they are contraindicated for PVD
Mammogram
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

34. Can we use beta blocker for pvd?
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Even after ochiopexy risk of ochiopexy higher then general population
Study showed no adverse effect; but they are contraindicated for PVD

35. surgery for acute cholecystities
Elderly and critically ill patients
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
24-48 hours of supportive therapy followed by cholecystectomy
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

36. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. SOB - confusion - petechial rash after trauma - fracture
Mammogram
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

38. What types of breast implants are available
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Saline and silicone
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

39. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Strok and traumatic brain injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

40. What is the contraindication of hyperventilation in inc ICP
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Strok and traumatic brain injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

41. Why right varicocele is more concerning?

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42. when patient with severe lung disease have C02 retention
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Patellar tendon tear; difficulty in extension
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

43. stress fx
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Even after ochiopexy risk of ochiopexy higher then general population
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

44. mangement of localized lymphadenopathy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Dumping syndrome; small and frequent meals; no simple sugar
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

45. lacerated wound in palmer surface of hand. what structure is injured?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Ispilateral hypoglossal nerve injury
Tendons more likely
Dm neuropathy; stocking glove pattern

46. pregnant patient with asymptomatic gall stones
Headache - ataxia - bulbar dysfunction
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

47. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

48. most frequent complication of TURP
Nonunion and avascular necrosis; fx can block blood supply;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Retrograde ejaculation
If patient ambulatory - surgery and pain control; if not nonop mx

49. What time frame required for bone remodeling
10-12 months
Saline and silicone
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
15-40%; self limiting;doesn't require tx

50. perioral numbness after parathyroidectomy
Ispilateral hypoglossal nerve injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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