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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. beta HCG
Seminomas
Saline and silicone
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
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

2. differential of ultrasound finding of breast mass
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

3. What time frame required for bone remodeling
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
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;

4. How to evaluate painless testicular swelling suspicious for cancer
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
S2-S4
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

5. What are the common injuries from lightning?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
50%; tunneling between rectum or kin
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
When urethral catherization is unsuccessful

6. mx of stress fx
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
Malignancy until proven otherwise
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

7. DD of acute scrotal pain
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Malignancy until proven otherwise

8. acute colonic ischemia
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

9. aspiration of breast cyst is nonbloody
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
24-48 hours of supportive therapy followed by cholecystectomy

10. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
CRPS
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

11. How varicocele causes testicular atrophy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4-6 weeks for noncontact sports and longer time for contact sports

12. anal sphincter tone
15-40%; self limiting;doesn't require tx
S2-S4
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
Supraglottic edema; low threshold for intubation

13. When do we see complications due to hypophosphatemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;
Check ET tube placement if correct needle decompresion

14. Valgus and Varus tests
Headache - ataxia - bulbar dysfunction
Strok and traumatic brain injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

15. What is most common lung injury after blunt chest trauma?
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
Less than 5mm
Progressive fibrosis of palmar fascia. etiololgy not known;
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

16. most common fx when falling on outsretched hand
Carpal tunnel syndrom
24-48 hours of supportive therapy followed by cholecystectomy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Headache - ataxia - bulbar dysfunction

17. how ABI help dx of PVD
4-6 weeks for noncontact sports and longer time for contact sports
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Ispilateral hypoglossal nerve injury

18. acalculus cholecystitis
Elderly and critically ill patients
Urethral stricture; pelvic of urethral trauma
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Next best step surgery; not ultrasound

19. 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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Subphrenic abscess or other abdominal abscesses; order US or CT
Amoxicillin-clavulanate

20. lacunar stroke
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
10-12 months
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
Pure motor stroke; limited neurological dysfunction

21. How to manage obesity
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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

22. 3 mo with groin bulge; bulge appears when child cries
Nonunion and avascular necrosis; fx can block blood supply;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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;
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

23. xray finding of stress fx after 3-4w
Progressive fibrosis of palmar fascia. etiololgy not known;
Less than 5mm
Pure motor stroke; limited neurological dysfunction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

24. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

25. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
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
15-40%; self limiting;doesn't require tx
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

26. varicocele
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If any compressive symptoms eg. dysphagia

27. 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
Carpal tunnel syndrom
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

28. stress fx
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Klinefelter syndrome; 50 fold increase;
Even after ochiopexy risk of ochiopexy higher then general population

29. How to manage a patient with asystole
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
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
Epi and chest compressio for prolong period of time; atropine is given after epi;

30. management of hip fracture
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If patient ambulatory - surgery and pain control; if not nonop mx
ACL injury
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

31. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Saline and silicone
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

32. What is cushing's triad
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;
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

33. perioral numbness after parathyroidectomy
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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;
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
Compression stocking - weight reduction - leg elevation

34. diarrhoea 4-5 days after cholecystectomy
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

35. When to stop raloxifene before surgery
Pure motor stroke; limited neurological dysfunction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

36. How mcmurray manuver perform
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

37. When to do surgery in undesceneded testis?
Elevated non seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dm neuropathy; stocking glove pattern

38. tx distal rectal ca
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;
Saline and silicone
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Nonunion and avascular necrosis; fx can block blood supply;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Unilateral vocal cord paralysis

40. antibiotics of acute cholecystitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Abd pain and tenderness; bloody diarrhoea or hematochezia
4-6 weeks for noncontact sports and longer time for contact sports

41. inhalation of hot air - steam - smoke in burn victim
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Supraglottic edema; low threshold for intubation
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
SAH due to post communicating artery aneurysm;

42. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

43. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Compression stocking - weight reduction - leg elevation
Supraglottic edema; low threshold for intubation
Epi and chest compressio for prolong period of time; atropine is given after epi;

44. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Check ET tube placement if correct needle decompresion
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

45. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Elevated non seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Nonunion and avascular necrosis; fx can block blood supply;

46. dorsiflexion and planter flexion
L5 to S2
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

47. Why initial xrays are negative in scaphoid fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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

48. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

49. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ACL injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

50. 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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Next best step surgery; not ultrasound
If any compressive symptoms eg. dysphagia