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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. stress fx
Elderly and critically ill patients
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

2. ct scan; cystic lesion in head of pancreas; next step
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

3. clavicle fx
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Displaced ORIF ; nondisplaced sling immobilization

4. sudden onset of postoperative hyperglycemia when patient on TPN
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

5. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Carpal tunnel syndrom
Even after ochiopexy risk of ochiopexy higher then general population
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
SAH due to post communicating artery aneurysm;

6. first step for evaluation of testicular swelling
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

7. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dumping syndrome; small and frequent meals; no simple sugar
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

8. What is the complications of undescended testis
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Less than 5mm
Displaced ORIF ; nondisplaced sling immobilization
Even after ochiopexy risk of ochiopexy higher then general population

9. varicose veins with ulcer - bleeding and thrombophlebitits
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
15-40%; self limiting;doesn't require tx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

10. When goiter needs surgery
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
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
L5 to S2
If any compressive symptoms eg. dysphagia

11. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

12. how hyperventilation lowers ICP
Mammogram
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Meniscus injury; medial most common; pain/swelling; popping sensation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

13. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

14. DD of acute scrotal pain
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Fx displace >1mm - nonunion during followup - osteonecrosis

15. Most common of sudden death due to steering wheel injury
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Next best step surgery; not ultrasound
Carpal tunnel syndrom

16. severe pain in leg after MVC
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
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

17. Tx of proximal non metastatic rectal ca
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
Study showed no adverse effect; but they are contraindicated for PVD
Low anterior resection and radio; add chemo if node positive

18. suprapubic catheterization
15-40%; self limiting;doesn't require tx
When urethral catherization is unsuccessful
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

19. Tx of pulmonary contusion
Headache - ataxia - bulbar dysfunction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

20. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Fx displace >1mm - nonunion during followup - osteonecrosis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

21. SOB - confusion - petechial rash after trauma - fracture
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

22. Indication for bariatric surgery in obese patients
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

23. dorsiflexion and planter flexion
Strok and traumatic brain injury
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;
Compression stocking - weight reduction - leg elevation

24. several knee pain after being tackled in football game
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Compression stocking - weight reduction - leg elevation
4-6 weeks for noncontact sports and longer time for contact sports

25. anal sphincter tone
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
S2-S4
Low anterior resection and radio; add chemo if node positive

26. Why varicocele more common in the left side
Subphrenic abscess or other abdominal abscesses; order US or CT
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

27. What are the common injuries from lightning?
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Saline and silicone
ACL injury

28. common complication of inadequate mx of scaphoid fx
Mammogram
Nonunion and avascular necrosis; fx can block blood supply;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

29. conservative Tx of varicose veins
Tendons more likely
Compression stocking - weight reduction - leg elevation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

30. acalculus cholecystitis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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;
Elderly and critically ill patients
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. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
SAH due to post communicating artery aneurysm;

32. What is prehn sign?
Abd pain and tenderness; bloody diarrhoea or hematochezia
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

33. xray finding of stress fx after 3-4w
Progressive fibrosis of palmar fascia. etiololgy not known;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Nonunion and avascular necrosis; fx can block blood supply;

34. How to evaluate painless testicular swelling suspicious for cancer
Carpal tunnel syndrom
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

35. What is terrible triad
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Patellar tendon tear; difficulty in extension
Mammogram

36. How to differentiate ACL and meniscus injury
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
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

37. Valgus and Varus tests
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
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;

38. mx of stress fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Headache - ataxia - bulbar dysfunction
Compression stocking - weight reduction - leg elevation

39. diarrhoea 4-5 days after cholecystectomy
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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
4-6 weeks for noncontact sports and longer time for contact sports
Subphrenic abscess or other abdominal abscesses; order US or CT

40. dumping syndrome after gastrectomy
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Abd pain and tenderness; bloody diarrhoea or hematochezia
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

41. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
If patient ambulatory - surgery and pain control; if not nonop mx
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

42. How to dx ACL tear?
Displaced ORIF ; nondisplaced sling immobilization
Malignancy until proven otherwise
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

43. management of gunshot wound
24-48 hours of supportive therapy followed by cholecystectomy
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

44. Why right varicocele is more concerning?

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45. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
4-6 weeks for noncontact sports and longer time for contact sports
Dm neuropathy; stocking glove pattern
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

46. when scaphoid fx patient needs to be referred to orthopedic
Progressive fibrosis of palmar fascia. etiololgy not known;
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
CRPS
Fx displace >1mm - nonunion during followup - osteonecrosis

47. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
SAH due to post communicating artery aneurysm;
If patient ambulatory - surgery and pain control; if not nonop mx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

48. varicocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elderly and critically ill patients
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

49. When patient can go back to sports after clavicle fx
Patellar tendon tear; difficulty in extension
4-6 weeks for noncontact sports and longer time for contact sports
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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;

50. antibiotics of acute cholecystitis
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Low anterior resection and radio; add chemo if node positive
Study showed no adverse effect; but they are contraindicated for PVD