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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. characteristics of ureteral stone?
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If patient ambulatory - surgery and pain control; if not nonop mx
Check ET tube placement if correct needle decompresion
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

2. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Dm neuropathy; stocking glove pattern
Subphrenic abscess or other abdominal abscesses; order US or CT
Meniscus injury; medial most common; pain/swelling; popping sensation
Dumping syndrome; small and frequent meals; no simple sugar

3. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Pure motor stroke; limited neurological dysfunction

4. acalculus cholecystitis
Elderly and critically ill patients
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Subphrenic abscess or other abdominal abscesses; order US or CT

5. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Strok and traumatic brain injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

6. How to confirm achiles tendon rupture
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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
Seminomas

7. recurrent laryngeal nerve injury
When urethral catherization is unsuccessful
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
Dumping syndrome; small and frequent meals; no simple sugar
Unilateral vocal cord paralysis

8. inhalation of hot air - steam - smoke in burn victim
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Meniscus injury; medial most common; pain/swelling; popping sensation
Supraglottic edema; low threshold for intubation
Dm neuropathy; stocking glove pattern

9. What is most common lung injury after blunt chest trauma?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

10. pregnant patient with asymptomatic gall stones
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
24-48 hours of supportive therapy followed by cholecystectomy

11. suprapubic catheterization
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
When urethral catherization is unsuccessful
Displaced ORIF ; nondisplaced sling immobilization

12. What is cushing's triad
Brardycardia - HTN - resp depression
Klinefelter syndrome; 50 fold increase;
Even after ochiopexy risk of ochiopexy higher then general population
Headache - ataxia - bulbar dysfunction

13. Can we use beta blocker for pvd?
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Epi and chest compressio for prolong period of time; atropine is given after epi;
Study showed no adverse effect; but they are contraindicated for PVD
Mammogram

14. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Amoxicillin-clavulanate
Epi and chest compressio for prolong period of time; atropine is given after epi;

15. first line of management of PVD
Epi and chest compressio for prolong period of time; atropine is given after epi;
Twisting force with the foot fixed on the ground seen in football and basketball games;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

16. when scaphoid fx patient needs to be referred to orthopedic
Patellar tendon tear; difficulty in extension
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Fx displace >1mm - nonunion during followup - osteonecrosis
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

17. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If any compressive symptoms eg. dysphagia
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

18. 3 mo with groin bulge; bulge appears when child cries
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Twisting force with the foot fixed on the ground seen in football and basketball games;

19. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
SAH due to post communicating artery aneurysm;
ACL injury

20. how ABI help dx of PVD
Displaced ORIF ; nondisplaced sling immobilization
50%; tunneling between rectum or kin
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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. Why right varicocele is more concerning?

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22. painless testicular mass in young male
Twisting force with the foot fixed on the ground seen in football and basketball games;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;
Malignancy until proven otherwise

23. How to manage a patient with asystole
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

24. cremasteric reflex
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevated non seminomas
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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. what size of ureteral stone for non op mx
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Less than 5mm
Elderly and critically ill patients

26. How to differentiate ACL and meniscus 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
Mammogram
10-12 months
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

27. managment of animal bite in hands
Seminomas
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
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;
Tendons more likely

28. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
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
Meniscus injury; medial most common; pain/swelling; popping sensation

29. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

30. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

31. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

32. first step for evaluation of testicular swelling
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Brardycardia - HTN - resp depression

33. varicocele
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2
Subphrenic abscess or other abdominal abscesses; order US or CT
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

34. Why varicocele more common in the left side
Subphrenic abscess or other abdominal abscesses; order US or CT
Amoxicillin-clavulanate
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

35. management of hip fracture
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
Ispilateral hypoglossal nerve injury
If patient ambulatory - surgery and pain control; if not nonop mx

36. Why initial xrays are negative in scaphoid fx
Elderly and critically ill patients
Mammogram
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
15-40%; self limiting;doesn't require tx

37. How to differentiate communicative and non-communicative hydrocele
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

38. mx of stress fx
Patellar tendon tear; difficulty in extension
Unilateral vocal cord paralysis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Abd pain and tenderness; bloody diarrhoea or hematochezia

39. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Abd pain and tenderness; bloody diarrhoea or hematochezia
Headache - ataxia - bulbar dysfunction
If patient ambulatory - surgery and pain control; if not nonop mx

40. diarrhoea 4-5 days after cholecystectomy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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;

41. 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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

42. What is the contraindication of hyperventilation in inc ICP
Strok and traumatic brain injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT

43. How to evaluate painless testicular swelling suspicious for cancer
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Check ET tube placement if correct needle decompresion
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

44. transrectal prostate biopsy
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
L5 to S2

45. Most common of sudden death due to steering wheel injury
Nonunion and avascular necrosis; fx can block blood supply;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Fx displace >1mm - nonunion during followup - osteonecrosis

46. contraindication of urethral catheterization
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
Urethral stricture; pelvic of urethral trauma

47. What is terrible triad
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Epi and chest compressio for prolong period of time; atropine is given after epi;
Tendons more likely
MAT; medial meniscus injury; ACL and Tibial colateral ligament

48. acute colonic ischemia
Amoxicillin-clavulanate
Abd pain and tenderness; bloody diarrhoea or hematochezia
Study showed no adverse effect; but they are contraindicated for PVD
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

49. scrotal trauma
Urethral stricture; pelvic of urethral trauma
Headache - ataxia - bulbar dysfunction
Next best step surgery; not ultrasound
Increased size during the day and valsalva means it is communicated with peritoneal cavity

50. What is hydrocele?
L5 to S2
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
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;