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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. cat/dog bites
Malignancy until proven otherwise
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Dumping syndrome; small and frequent meals; no simple sugar
Amoxicillin-clavulanate

2. When patient can go back to sports after clavicle fx
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Ispilateral hypoglossal nerve injury
4-6 weeks for noncontact sports and longer time for contact sports

3. Why right varicocele is more concerning?

4. Indication for bariatric surgery in obese patients
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;
Compression stocking - weight reduction - leg elevation
S2-S4
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

5. Why ruq calcificaion is concerning
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
4-6 weeks for noncontact sports and longer time for contact sports
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

6. How to perform lachman test
Sphincter sparing surgery (local resection) - abdomnio perineal resection
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Malignancy until proven otherwise
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

7. beta hcg and AFP
Elevated non seminomas
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

8. how ABI help dx of PVD
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Klinefelter syndrome; 50 fold increase;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

9. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Dm neuropathy; stocking glove pattern
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

10. Most common of sudden death due to steering wheel injury
4-6 weeks for noncontact sports and longer time for contact sports
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Twisting force with the foot fixed on the ground seen in football and basketball games;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

11. common complication of inadequate mx of scaphoid fx
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Nonunion and avascular necrosis; fx can block blood supply;
Tendons more likely
Urethral stricture; pelvic of urethral trauma

12. complication displaced or communited distal radial fx
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Carpal tunnel syndrom
Check ET tube placement if correct needle decompresion

13. What types of breast implants are available
24-48 hours of supportive therapy followed by cholecystectomy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Saline and silicone
If any compressive symptoms eg. dysphagia

14. What time frame required for bone remodeling
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Saline and silicone
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
10-12 months

15. indication of ursodeoxycholic acid
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
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
Amoxicillin-clavulanate

16. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Study showed no adverse effect; but they are contraindicated for PVD
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

17. Tx of pulmonary contusion
10-12 months
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

18. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Displaced ORIF ; nondisplaced sling immobilization
Fx displace >1mm - nonunion during followup - osteonecrosis
Patellar tendon tear; difficulty in extension

19. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

20. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
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
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

21. what size of ureteral stone for non op mx
Less than 5mm
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dm neuropathy; stocking glove pattern
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

22. dumping syndrome after gastrectomy
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

23. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
4-6 weeks for noncontact sports and longer time for contact sports
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

24. How to confirm dx of compartment syndrom
Nonunion and avascular necrosis; fx can block blood supply;
Elderly and critically ill patients
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

25. several knee pain after being tackled in football game
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Next best step surgery; not ultrasound
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

26. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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;
SAH due to post communicating artery aneurysm;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
L5 to S2

27. differential of ultrasound finding of breast mass
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Meniscus injury; medial most common; pain/swelling; popping sensation
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

28. popping sensation; rapid onset of knee effusion. athelet
Even after ochiopexy risk of ochiopexy higher then general population
If any compressive symptoms eg. dysphagia
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
ACL injury

29. xray finding of stress fx after 3-4w
Seminomas
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

30. SOB - confusion - petechial rash after trauma - fracture
15-40%; self limiting;doesn't require tx
Headache - ataxia - bulbar dysfunction
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

31. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Less than 5mm

32. 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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Next best step surgery; not ultrasound
Ispilateral hypoglossal nerve injury

33. What is prehn sign?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
24-48 hours of supportive therapy followed by cholecystectomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Next best step surgery; not ultrasound

34. DD of acute scrotal pain
Klinefelter syndrome; 50 fold increase;
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

35. When to stop raloxifene before surgery
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

36. How to manage obesity
Retrograde ejaculation
Tendons more likely
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Saline and silicone

37. What is the strongest risk factor for male breast cancer
24-48 hours of supportive therapy followed by cholecystectomy
Nonunion and avascular necrosis; fx can block blood supply;
Klinefelter syndrome; 50 fold increase;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

38. Complications of breast impant
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
S2-S4
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

39. dorsiflexion and planter flexion
L5 to S2
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
ACL injury
50%; tunneling between rectum or kin

40. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
15-40%; self limiting;doesn't require tx

41. Valgus and Varus tests
Less than 5mm
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

42. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

43. mangement of localized lymphadenopathy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

44. diarrhoea 4-5 days after cholecystectomy
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;
Pure motor stroke; limited neurological dysfunction
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

45. When do we see complications due to hypophosphatemia
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Even after ochiopexy risk of ochiopexy higher then general population
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

46. When to do surgery in undesceneded testis?
Dumping syndrome; small and frequent meals; no simple sugar
Urethral stricture; pelvic of urethral trauma
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

47. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

48. What is hungry bone syndrome?
L5 to S2
If any compressive symptoms eg. dysphagia
Strok and traumatic brain injury
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

49. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

50. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
If patient ambulatory - surgery and pain control; if not nonop mx
Pure motor stroke; limited neurological dysfunction