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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. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Patellar tendon tear; difficulty in extension
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

2. anal sphincter tone
S2-S4
Unilateral vocal cord paralysis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

3. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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 large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Supraglottic edema; low threshold for intubation

4. Complications of breast impant
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Check ET tube placement if correct needle decompresion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

5. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
Check ET tube placement if correct needle decompresion
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

6. ct scan; cystic lesion in head of pancreas; next step
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

7. What is most common lung injury after blunt chest trauma?
Malignancy until proven otherwise
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
4-6 weeks for noncontact sports and longer time for contact sports

8. when scaphoid fx patient needs to be referred to orthopedic
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Fx displace >1mm - nonunion during followup - osteonecrosis
Saline and silicone
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

9. differential of ultrasound finding of breast mass
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Seminomas
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

10. diarrhoea 4-5 days after cholecystectomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

11. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

12. How to perform lachman test
Subphrenic abscess or other abdominal abscesses; order US or CT
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased size during the day and valsalva means it is communicated with peritoneal cavity

13. management of stone 8-10mm
Urethral stricture; pelvic of urethral trauma
Displaced ORIF ; nondisplaced sling immobilization
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
S2-S4

14. inhalation of hot air - steam - smoke in burn victim
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
Supraglottic edema; low threshold for intubation
Unilateral vocal cord paralysis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

15. painless testicular mass in young male
Supraglottic edema; low threshold for intubation
Malignancy until proven otherwise
Progressive fibrosis of palmar fascia. etiololgy not known;
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

16. several knee pain after being tackled in football game
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

17. varicocele
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Headache - ataxia - bulbar dysfunction
Saline and silicone
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

18. What is the strongest risk factor for male breast cancer
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Klinefelter syndrome; 50 fold increase;
Seminomas

19. What time frame required for bone remodeling
4-6 weeks for noncontact sports and longer time for contact sports
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sphincter sparing surgery (local resection) - abdomnio perineal resection
10-12 months

20. Why right varicocele is more concerning?

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21. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Saline and silicone
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

22. beta HCG
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Seminomas
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Malignancy until proven otherwise

23. pregnant patient with asymptomatic gall stones
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

24. sudden onset of postoperative hyperglycemia when patient on TPN
Strok and traumatic brain injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

25. What is hungry bone syndrome?
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Study showed no adverse effect; but they are contraindicated for PVD
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

26. What is the contraindication of hyperventilation in inc ICP
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
Brardycardia - HTN - resp depression
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Strok and traumatic brain injury

27. How to confirm achiles tendon rupture
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
Next best step surgery; not ultrasound
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
When urethral catherization is unsuccessful

28. clavicle fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dumping syndrome; small and frequent meals; no simple sugar
Displaced ORIF ; nondisplaced sling immobilization
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

29. indication of ursodeoxycholic acid
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
4-6 weeks for noncontact sports and longer time for contact sports

30. popping sensation; rapid onset of knee effusion. athelet
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
ACL injury
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

31. SOB - confusion - petechial rash after trauma - fracture
Amoxicillin-clavulanate
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

32. types of hip fracture
15-40%; self limiting;doesn't require tx
Subphrenic abscess or other abdominal abscesses; order US or CT
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Elevated non seminomas

33. management of gunshot wound
10-12 months
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Sphincter sparing surgery (local resection) - abdomnio perineal resection

34. 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;
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
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
Malignancy until proven otherwise

35. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Check ET tube placement if correct needle decompresion
Elevated non seminomas

36. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Mammogram
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Twisting force with the foot fixed on the ground seen in football and basketball games;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

37. acalculus cholecystitis
Elderly and critically ill patients
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Patellar tendon tear; difficulty in extension
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

38. Why varicocele more common in the left side
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

39. surgery for acute cholecystities
SAH due to post communicating artery aneurysm;
24-48 hours of supportive therapy followed by 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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

40. most frequent complication of TURP
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Retrograde ejaculation

41. When patient can go back to sports after clavicle fx
ACL injury
Less than 5mm
4-6 weeks for noncontact sports and longer time for contact sports
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

42. managment of animal bite in hands
MAT; medial meniscus injury; ACL and Tibial colateral ligament
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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;

43. dorsiflexion and planter flexion
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
L5 to S2

44. management of nondisplaced scaphoid fx
CRPS
Unilateral vocal cord paralysis
Brardycardia - HTN - resp depression
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

45. xray finding of stress fx after 3-4w
Seminomas
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

46. Tx of pulmonary contusion
Less than 5mm
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

47. How to differentiate ACL and meniscus injury
Compression stocking - weight reduction - leg elevation
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
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
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;

48. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
CRPS
Subphrenic abscess or other abdominal abscesses; order US or CT
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

49. swelling and tenderness in anterior part of knee
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;
Less than 5mm
Twisting force with the foot fixed on the ground seen in football and basketball games;
Patellar tendon tear; difficulty in extension

50. What is cushing's triad
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
Strok and traumatic brain injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Brardycardia - HTN - resp depression