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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. managment of animal bite in hands
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Retrograde ejaculation
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

2. clavicle fx
S2-S4
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization
If any compressive symptoms eg. dysphagia

3. what size of ureteral stone for non op mx
Seminomas
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Abd pain and tenderness; bloody diarrhoea or hematochezia
Less than 5mm

4. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Supraglottic edema; low threshold for intubation
CRPS

5. varicose veins with ulcer - bleeding and thrombophlebitits
SAH due to post communicating artery aneurysm;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

6. most common fx when falling on outsretched hand
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

7. When goiter needs surgery
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
4-6 weeks for noncontact sports and longer time for contact sports
If any compressive symptoms eg. dysphagia
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

8. How to differentiate communicative and non-communicative hydrocele
Headache - ataxia - bulbar 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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

9. mx of stress fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

10. How to dx ACL tear?
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
Less than 5mm
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

11. Valgus and Varus tests
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Low anterior resection and radio; add chemo if node positive
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;

12. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Ispilateral hypoglossal nerve injury

13. What is prehn sign?
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

14. dumping syndrome after gastrectomy
Tendons more likely
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;

15. How to confirm achiles tendon rupture
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
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;

16. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
Retrograde ejaculation
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Epi and chest compressio for prolong period of time; atropine is given after epi;

17. sudden onset of postoperative hyperglycemia when patient on TPN
Mammogram
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

18. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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;
Ispilateral hypoglossal nerve injury

19. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
ACL injury
L5 to S2
Cystic scrotal fluid collection between parietal and visceral layers of testis

20. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Malignancy until proven otherwise

21. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
50%; tunneling between rectum or kin

22. menisci injury
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
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
Urethral stricture; pelvic of urethral trauma
Twisting force with the foot fixed on the ground seen in football and basketball games;

23. pregnant patient with asymptomatic gall stones
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

24. dorsiflexion and planter flexion
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
L5 to S2
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

25. What are the common injuries from lightning?
Compression stocking - weight reduction - leg elevation
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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;

26. most frequent complication of TURP
Carpal tunnel syndrom
Displaced ORIF ; nondisplaced sling immobilization
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;
Retrograde ejaculation

27. Why right varicocele is more concerning?

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28. Complications of breast impant
CRPS
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Elevated non seminomas
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

29. Incidence of AF in CABG patient

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30. prostate enlarged - nontender - no nodularity - elevated PSA
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
S2-S4

31. lacerated wound in palmer surface of hand. what structure is injured?
Retrograde ejaculation
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Unilateral vocal cord paralysis
Tendons more likely

32. What is hungry bone syndrome?
Brardycardia - HTN - resp depression
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

33. When patient can go back to sports after clavicle fx
Subphrenic abscess or other abdominal abscesses; order US or CT
4-6 weeks for noncontact sports and longer time for contact sports
Ampicillin sublactum - pipercillin - ceftriaxone and metro
MAT; medial meniscus injury; ACL and Tibial colateral ligament

34. What is the strongest risk factor for male breast cancer
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Supraglottic edema; low threshold for intubation
Klinefelter syndrome; 50 fold increase;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

35. How to evaluate painless testicular swelling suspicious for cancer
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Next best step surgery; not ultrasound
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;
Seminomas

36. when patient with severe lung disease have C02 retention
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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 size during the day and valsalva means it is communicated with peritoneal cavity
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

37. first step for evaluation of testicular swelling
Mammogram
Seminomas
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

38. 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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

39. how ABI help dx of PVD
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Fx displace >1mm - nonunion during followup - osteonecrosis
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

40. how hyperventilation lowers ICP
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Fx displace >1mm - nonunion during followup - osteonecrosis
Abd pain and tenderness; bloody diarrhoea or hematochezia
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

41. What is cushing's triad
Less than 5mm
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;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. several knee pain after being tackled in football game
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

43. beta hcg and AFP
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Dm neuropathy; stocking glove pattern
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevated non seminomas

44. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

45. When do we see complications due to hypophosphatemia
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;
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Amoxicillin-clavulanate

46. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

47. conservative Tx of varicose veins
Cystic scrotal fluid collection between parietal and visceral layers of testis
Compression stocking - weight reduction - leg elevation
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Fx displace >1mm - nonunion during followup - osteonecrosis

48. How varicocele causes testicular atrophy
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

49. indication of ursodeoxycholic acid
Elevated non seminomas
Subphrenic abscess or other abdominal abscesses; order US or CT
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
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. SAH due to posterior inferior cerebellar aneurysm
Less than 5mm
Headache - ataxia - bulbar dysfunction
Seminomas
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