Test your basic knowledge |

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. when scaphoid fx patient needs to be referred to orthopedic
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Fx displace >1mm - nonunion during followup - osteonecrosis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

2. 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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Meniscus injury; medial most common; pain/swelling; popping sensation

3. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
When urethral catherization is unsuccessful
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

4. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Less than 5mm

5. several knee pain after being tackled in football game
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
24-48 hours of supportive therapy followed by cholecystectomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

6. What is cushing's triad
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Brardycardia - HTN - resp depression
Elevated non seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis

7. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

8. ipsilateral deviation of tongue upon protrusion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Ispilateral hypoglossal nerve injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Twisting force with the foot fixed on the ground seen in football and basketball games;

9. Why right varicocele is more concerning?

10. characteristics of ureteral stone?
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

11. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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;
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
Check ET tube placement if correct needle decompresion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

12. dumping syndrome after gastrectomy
Strok and traumatic brain injury
Dm neuropathy; stocking glove pattern
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

13. What is prehn sign?
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;

14. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
15-40%; self limiting;doesn't require tx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
SAH due to post communicating artery aneurysm;

15. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Dumping syndrome; small and frequent meals; no simple sugar
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

16. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Elderly and critically ill patients

17. When to do surgery in undesceneded testis?
Strok and traumatic brain injury
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Meniscus injury; medial most common; pain/swelling; popping sensation

18. contraindication of urethral catheterization
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Urethral stricture; pelvic of urethral trauma
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

19. cremasteric reflex test?
Meniscus injury; medial most common; pain/swelling; popping sensation
Less than 5mm
Brardycardia - HTN - resp depression
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

20. prostate enlarged - nontender - no nodularity - elevated PSA
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Fx displace >1mm - nonunion during followup - osteonecrosis
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
SAH due to post communicating artery aneurysm;

21. how hyperventilation lowers ICP
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Mammogram
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

22. DD of acute scrotal pain
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Check ET tube placement if correct needle decompresion
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

23. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Dumping syndrome; small and frequent meals; no simple sugar
If any compressive symptoms eg. dysphagia
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

24. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Strok and traumatic brain injury
Tendons more likely

25. tx distal rectal ca
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sphincter sparing surgery (local resection) - abdomnio perineal resection

26. cat/dog bites
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Amoxicillin-clavulanate
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Supraglottic edema; low threshold for intubation

27. beta HCG
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;
Seminomas
Even after ochiopexy risk of ochiopexy higher then general population

28. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
L5 to S2
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

29. SOB - confusion - petechial rash after trauma - fracture
Tendons more likely
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Even after ochiopexy risk of ochiopexy higher then general population

30. How to evaluate painless testicular swelling suspicious for cancer
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

31. What is terrible triad
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Progressive fibrosis of palmar fascia. etiololgy not known;

32. 3 mo with groin bulge; bulge appears when child cries
Unilateral vocal cord paralysis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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. xray finding of stress fx after 3-4w
ACL injury
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

34. management of gunshot wound
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Meniscus injury; medial most common; pain/swelling; popping sensation
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

35. suprapubic catheterization
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
24-48 hours of supportive therapy followed by cholecystectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
When urethral catherization is unsuccessful

36. anal sphincter tone
Seminomas
If patient ambulatory - surgery and pain control; if not nonop mx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
S2-S4

37. When to stop raloxifene before surgery
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

38. 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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

39. complications of TPN
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
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
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

40. management of stone 8-10mm
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;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

41. What types of breast implants are available
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Saline and silicone
4-6 weeks for noncontact sports and longer time for contact sports
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

42. How to dx ACL tear?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Urethral stricture; pelvic of urethral trauma
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

43. first line of management of PVD
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
L5 to S2
If patient ambulatory - surgery and pain control; if not nonop mx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

44. diarrhoea 4-5 days after cholecystectomy
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
Saline and silicone
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

45. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Subphrenic abscess or other abdominal abscesses; order US or CT

46. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension
10-12 months
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

47. stress fx
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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

48. swelling and tenderness in anterior part of knee
Elderly and critically ill patients
Next best step surgery; not ultrasound
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Patellar tendon tear; difficulty in extension

49. Most common of sudden death due to steering wheel injury
Elderly and critically ill patients
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

50. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Elevated non seminomas
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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