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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. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Retrograde ejaculation
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
Seminomas

2. varicocele
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
24-48 hours of supportive therapy followed by cholecystectomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

3. when scaphoid fx patient needs to be referred to orthopedic
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Fx displace >1mm - nonunion during followup - osteonecrosis
When urethral catherization is unsuccessful

4. Indication for bariatric surgery in obese patients
Ispilateral hypoglossal nerve injury
SAH due to post communicating artery aneurysm;
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
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;

5. Why varicocele more common in the left side
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;
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 drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

6. cat/dog bites
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
Amoxicillin-clavulanate
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
10-12 months

7. What percent of anal abscess deveolop fisutula
CRPS
If any compressive symptoms eg. dysphagia
50%; tunneling between rectum or kin
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

8. How to manage obesity
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Dumping syndrome; small and frequent meals; no simple sugar

9. clavicle fx
S2-S4
Displaced ORIF ; nondisplaced sling immobilization
Mammogram
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

10. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Subphrenic abscess or other abdominal abscesses; order US or CT
Compression stocking - weight reduction - leg elevation
Headache - ataxia - bulbar dysfunction

11. conservative Tx of varicose veins
L5 to S2
Compression stocking - weight reduction - leg elevation
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;
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

12. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
10-12 months
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

13. management of stone 8-10mm
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
<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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

14. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Meniscus injury; medial most common; pain/swelling; popping sensation
Displaced ORIF ; nondisplaced sling immobilization
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

15. perioral numbness after parathyroidectomy
Urethral stricture; pelvic of urethral trauma
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
Headache - ataxia - bulbar dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

16. managment of animal bite in hands
Elevated non seminomas
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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;
Seminomas

17. What is hungry bone syndrome?
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
Pure motor stroke; limited neurological dysfunction
Epi and chest compressio for prolong period of time; atropine is given after epi;
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

18. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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;
Displaced ORIF ; nondisplaced sling immobilization
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;
Dm neuropathy; stocking glove pattern

19. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Nonunion and avascular necrosis; fx can block blood supply;
Patellar tendon tear; difficulty in extension
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

20. acute colonic ischemia
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

21. Patient underwent CABG; postoperatively drowsy. most likely cause?
4-6 weeks for noncontact sports and longer time for contact sports
Urethral stricture; pelvic of urethral trauma
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

22. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Carpal tunnel syndrom
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
50%; tunneling between rectum or kin
Brardycardia - HTN - resp depression

23. stress fx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Headache - ataxia - bulbar dysfunction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

24. how ABI help dx of PVD
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

25. aspiration of breast cyst is nonbloody
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
When urethral catherization is unsuccessful

26. When to do surgery in undesceneded testis?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

27. beta HCG
Dm neuropathy; stocking glove pattern
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
Headache - ataxia - bulbar dysfunction
Seminomas

28. acalculus cholecystitis
Strok and traumatic brain injury
Elderly and critically ill patients
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Fx displace >1mm - nonunion during followup - osteonecrosis

29. lacerated wound in palmer surface of hand. what structure is injured?
Subphrenic abscess or other abdominal abscesses; order US or CT
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Tendons more likely

30. management of gunshot wound
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
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;
Carpal tunnel syndrom
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

31. beta hcg and AFP
Brardycardia - HTN - resp depression
Elevated non seminomas
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

32. indication of ursodeoxycholic acid
Supraglottic edema; low threshold for intubation
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

33. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Ispilateral hypoglossal nerve injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

34. painless testicular mass in young male
Malignancy until proven otherwise
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Subphrenic abscess or other abdominal abscesses; order US or CT
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
CRPS
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

36. dorsiflexion and planter flexion
L5 to S2
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

37. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Displaced ORIF ; nondisplaced sling immobilization
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

38. varicose veins with ulcer - bleeding and thrombophlebitits
Patellar tendon tear; difficulty in extension
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Seminomas
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

39. swelling and tenderness in anterior part of knee
Elderly and critically ill patients
Patellar tendon tear; difficulty in extension
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

40. How to confirm achiles tendon rupture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

41. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Elderly and critically ill patients
S2-S4
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

42. Tx of pulmonary contusion
Supraglottic edema; low threshold for intubation
Urethral stricture; pelvic of urethral trauma
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

43. 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
Unilateral vocal cord paralysis
Study showed no adverse effect; but they are contraindicated for PVD

44. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
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
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
Check ET tube placement if correct needle decompresion

45. How mcmurray manuver perform
Subphrenic abscess or other abdominal abscesses; order US or CT
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

46. 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
Check ET tube placement if correct needle decompresion
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Klinefelter syndrome; 50 fold increase;

47. aspiration of breast cyst is bloody
4-6 weeks for noncontact sports and longer time for contact sports
Mammogram
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Next best step surgery; not ultrasound

48. Why initial xrays are negative in scaphoid fx
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 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
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

49. prostate enlarged - nontender - no nodularity - elevated PSA
Low anterior resection and radio; add chemo if node positive
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

50. diarrhoea 4-5 days after cholecystectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Unilateral vocal cord paralysis
Even after ochiopexy risk of ochiopexy higher then general population