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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. How mcmurray manuver perform
4-6 weeks for noncontact sports and longer time for contact sports
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

2. diarrhoea after gastric bypass
Strok and traumatic brain injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dumping syndrome; small and frequent meals; no simple sugar
Compression stocking - weight reduction - leg elevation

3. What time frame required for bone remodeling
ACL injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
10-12 months

4. recurrent laryngeal nerve injury
Unilateral vocal cord paralysis
Elevated non seminomas
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

5. Dupuytren contracture
Study showed no adverse effect; but they are contraindicated for PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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
Progressive fibrosis of palmar fascia. etiololgy not known;

6. How to confirm achiles tendon rupture
Strok and traumatic brain injury
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

7. 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;
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Epi and chest compressio for prolong period of time; atropine is given after epi;

8. severe pain in leg after MVC
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
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

9. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Mammogram

10. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Saline and silicone
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

11. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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;
S2-S4
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

12. 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)
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Tendons more likely

13. anal sphincter tone
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
S2-S4

14. complication displaced or communited distal radial fx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Carpal tunnel syndrom
ACL injury
Headache - ataxia - bulbar dysfunction

15. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Tendons more likely
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

16. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Nonunion and avascular necrosis; fx can block blood supply;
When urethral catherization is unsuccessful
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

17. What is the complications of undescended testis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Even after ochiopexy risk of ochiopexy higher then general population
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
50%; tunneling between rectum or kin

18. when scaphoid fx patient needs to be referred to orthopedic
Amoxicillin-clavulanate
Fx displace >1mm - nonunion during followup - osteonecrosis
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

19. mx of stress fx
Mammogram
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

20. 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
Study showed no adverse effect; but they are contraindicated for PVD
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

21. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Dm neuropathy; stocking glove pattern
Nonunion and avascular necrosis; fx can block blood supply;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check ET tube placement if correct needle decompresion

22. menisci injury
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;
Retrograde ejaculation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

23. contraindication of urethral catheterization
Patellar tendon tear; difficulty in extension
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Urethral stricture; pelvic of urethral trauma

24. How to perform lachman test
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
Retrograde ejaculation
10-12 months
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

26. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD
Ispilateral hypoglossal nerve injury

27. What is the strongest risk factor for male breast cancer
Displaced ORIF ; nondisplaced sling immobilization
Klinefelter syndrome; 50 fold increase;
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

28. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If any compressive symptoms eg. dysphagia

29. When do we see complications due to hypophosphatemia
15-40%; self limiting;doesn't require tx
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
SAH due to post communicating artery aneurysm;
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
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
Subphrenic abscess or other abdominal abscesses; order US or CT

31. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Subphrenic abscess or other abdominal abscesses; order US or CT
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;

32. suprapubic catheterization
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Fx displace >1mm - nonunion during followup - osteonecrosis
When urethral catherization is unsuccessful

33. stress fx
15-40%; self limiting;doesn't require tx
Headache - ataxia - bulbar dysfunction
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Ampicillin sublactum - pipercillin - ceftriaxone and metro

34. Valgus and Varus tests
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
4-6 weeks for noncontact sports and longer time for contact sports
Ampicillin sublactum - pipercillin - ceftriaxone and metro

35. differential of ultrasound finding of breast mass
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fx displace >1mm - nonunion during followup - osteonecrosis
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
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

36. What types of breast implants are available
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Saline and silicone
Check ET tube placement if correct needle decompresion
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. how hyperventilation lowers ICP
Mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

38. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
If any compressive symptoms eg. dysphagia
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

39. How to manage obesity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Carpal tunnel syndrom

40. SOB - confusion - petechial rash after trauma - fracture
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;
10-12 months
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Displaced ORIF ; nondisplaced sling immobilization
Meniscus injury; medial most common; pain/swelling; popping sensation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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;

42. Why initial xrays are negative in scaphoid fx
Dm neuropathy; stocking glove pattern
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
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

43. clavicle fx
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
L5 to S2
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;
Displaced ORIF ; nondisplaced sling immobilization

44. How to manage a patient with asystole
Unilateral vocal cord paralysis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Epi and chest compressio for prolong period of time; atropine is given after epi;

45. Why right varicocele is more concerning?

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46. What are the common injuries from lightning?
Pure motor stroke; limited neurological dysfunction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Urethral stricture; pelvic of urethral trauma

47. Incidence of AF in CABG patient

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48. beta HCG
Seminomas
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

49. most common complication of acute cholecystitis
Dumping syndrome; small and frequent meals; no simple sugar
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
L5 to S2

50. transrectal prostate biopsy
Tendons more likely
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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