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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. cremasteric reflex
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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 drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

2. swelling and tenderness in anterior part of knee
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Patellar tendon tear; difficulty in extension
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Urethral stricture; pelvic of urethral trauma

3. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Twisting force with the foot fixed on the ground seen in football and basketball games;
Supraglottic edema; low threshold for intubation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

4. ct scan; cystic lesion in head of pancreas; next step
Even after ochiopexy risk of ochiopexy higher then general population
Carpal tunnel syndrom
If any compressive symptoms eg. dysphagia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

5. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

6. How to dx ACL tear?
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
S2-S4

7. when patient with severe lung disease have C02 retention
Carpal tunnel syndrom
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Saline and silicone

8. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
Nonunion and avascular necrosis; fx can block blood supply;

9. scrotal trauma
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Next best step surgery; not ultrasound
Headache - ataxia - bulbar dysfunction

10. What is terrible triad
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

11. acute colonic ischemia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

12. SOB - confusion - petechial rash after trauma - fracture
SAH due to post communicating artery aneurysm;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Malignancy until proven otherwise

13. When goiter needs surgery
Subphrenic abscess or other abdominal abscesses; order US or CT
If any compressive symptoms eg. dysphagia
Klinefelter syndrome; 50 fold increase;
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

14. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Mammogram
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elevated non seminomas

15. Why initial xrays are negative in scaphoid fx
Next best step surgery; not ultrasound
10-12 months
If patient ambulatory - surgery and pain control; if not nonop mx
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

16. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Dumping syndrome; small and frequent meals; no simple sugar

17. types of hip fracture
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
15-40%; self limiting;doesn't require tx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

18. How to differentiate communicative and non-communicative hydrocele
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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;

19. beta hcg and AFP
If patient ambulatory - surgery and pain control; if not nonop mx
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Compression stocking - weight reduction - leg elevation
Elevated non seminomas

20. aspiration of breast cyst is nonbloody
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis

21. 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
Displaced ORIF ; nondisplaced sling immobilization
Klinefelter syndrome; 50 fold increase;
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

22. How to confirm achiles tendon rupture
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Even after ochiopexy risk of ochiopexy higher then general population
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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

23. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

24. severe pain in leg after MVC
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
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

25. DD of acute scrotal pain
Meniscus injury; medial most common; pain/swelling; popping sensation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

26. pregnant patient with asymptomatic gall stones
Dumping syndrome; small and frequent meals; no simple sugar
SAH due to post communicating artery aneurysm;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Check ET tube placement if correct needle decompresion

27. 3 mo with groin bulge; bulge appears when child cries
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
L5 to S2

28. diarrhoea 4-5 days after cholecystectomy
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fx displace >1mm - nonunion during followup - osteonecrosis
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

29. how ABI help dx of PVD
Meniscus injury; medial most common; pain/swelling; popping sensation
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Dm neuropathy; stocking glove pattern
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

30. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If any compressive symptoms eg. dysphagia
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

31. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Strok and traumatic brain injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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

32. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Meniscus injury; medial most common; pain/swelling; popping sensation

33. first line of management of PVD
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Klinefelter syndrome; 50 fold increase;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

34. menisci injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Twisting force with the foot fixed on the ground seen in football and basketball games;

35. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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;
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
10-12 months

36. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Elderly and critically ill patients
Elevated non seminomas
Check ET tube placement if correct needle decompresion
Low anterior resection and radio; add chemo if node positive

37. recurrent laryngeal nerve injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Unilateral vocal cord paralysis
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

38. mx of stress fx
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Brardycardia - HTN - resp depression
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

39. characteristics of ureteral stone?
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Headache - ataxia - bulbar dysfunction
Brardycardia - HTN - resp depression

40. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Tendons more likely
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Epi and chest compressio for prolong period of time; atropine is given after epi;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

41. What is the strongest risk factor for male breast cancer
Increased size during the day and valsalva means it is communicated with peritoneal cavity
ACL injury
Klinefelter syndrome; 50 fold increase;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

42. diarrhoea after gastric bypass
Malignancy until proven otherwise
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;
Dumping syndrome; small and frequent meals; no simple sugar

43. What is the contraindication of hyperventilation in inc ICP
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Elevated non seminomas
Strok and traumatic brain injury

44. Incidence of AF in CABG patient

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45. What is hungry bone syndrome?
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

46. sudden onset of postoperative hyperglycemia when patient on TPN
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

47. contraindication of urethral catheterization
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
Compression stocking - weight reduction - leg elevation
Urethral stricture; pelvic of urethral trauma

48. suprapubic catheterization
ACL injury
When urethral catherization is unsuccessful
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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. anal sphincter tone
Epi and chest compressio for prolong period of time; atropine is given after epi;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Klinefelter syndrome; 50 fold increase;
S2-S4

50. lacerated wound in palmer surface of hand. what structure is injured?
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Tendons more likely
Elderly and critically ill patients
Progressive fibrosis of palmar fascia. etiololgy not known;