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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. when scaphoid fx patient needs to be referred to orthopedic
Twisting force with the foot fixed on the ground seen in football and basketball games;
Even after ochiopexy risk of ochiopexy higher then general population
Fx displace >1mm - nonunion during followup - osteonecrosis
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

2. what size of ureteral stone for non op mx
Strok and traumatic brain injury
Less than 5mm
Nonunion and avascular necrosis; fx can block blood supply;
CRPS

3. how hyperventilation lowers ICP
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
10-12 months

4. acalculus cholecystitis
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Elderly and critically ill patients
S2-S4

5. What is most common lung injury after blunt chest trauma?
Next best step surgery; not ultrasound
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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

6. When do we see complications due to hypophosphatemia
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
50%; tunneling between rectum or kin
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;

7. How varicocele causes testicular atrophy
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fx displace >1mm - nonunion during followup - osteonecrosis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

8. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Abd pain and tenderness; bloody diarrhoea or hematochezia
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

9. Patient underwent CABG; postoperatively drowsy. most likely cause?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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
Displaced ORIF ; nondisplaced sling immobilization
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

10. aspiration of breast cyst is bloody
Mammogram
When urethral catherization is unsuccessful
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;
Twisting force with the foot fixed on the ground seen in football and basketball games;

11. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
S2-S4

12. How to confirm dx of compartment syndrom
Less than 5mm
4-6 weeks for noncontact sports and longer time for contact sports
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

13. What is terrible triad
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Patellar tendon tear; difficulty in extension
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament

14. painless testicular mass in young male
Nonunion and avascular necrosis; fx can block blood supply;
Elderly and critically ill patients
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

15. stress fx
Patellar tendon tear; difficulty in extension
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
When urethral catherization is unsuccessful

16. How to manage obesity
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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

17. When to stop raloxifene before 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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Mammogram
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

18. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Seminomas
If any compressive symptoms eg. dysphagia
When urethral catherization is unsuccessful

19. perioral numbness after parathyroidectomy
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
Progressive fibrosis of palmar fascia. etiololgy not known;
24-48 hours of supportive therapy followed by cholecystectomy
SAH due to post communicating artery aneurysm;

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

21. When goiter needs surgery
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
If any compressive symptoms eg. dysphagia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

22. What percent of anal abscess deveolop fisutula
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
50%; tunneling between rectum or kin
Headache - ataxia - bulbar dysfunction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

23. midline neck swelling moves with protrusion of tongue
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Next best step surgery; not ultrasound
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

24. when patient with severe lung disease have C02 retention
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Amoxicillin-clavulanate
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

25. severe pain in leg after MVC
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Strok and traumatic brain injury

26. When patient can go back to sports after clavicle fx
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
4-6 weeks for noncontact sports and longer time for contact sports
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Unilateral vocal cord paralysis

27. transrectal prostate biopsy
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
50%; tunneling between rectum or kin
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

28. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

29. sudden onset of postoperative hyperglycemia when patient on TPN
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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
If patient ambulatory - surgery and pain control; if not nonop mx
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

30. diarrhoea 4-5 days after cholecystectomy
Carpal tunnel syndrom
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

31. xray finding of stress fx after 3-4w
Next best step surgery; not ultrasound
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Ampicillin sublactum - pipercillin - ceftriaxone and metro

32. 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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
When urethral catherization is unsuccessful
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

33. clavicle fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Displaced ORIF ; nondisplaced sling immobilization
Less than 5mm
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

34. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Pure motor stroke; limited neurological dysfunction
Mammogram
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

35. Indication for bariatric surgery in obese patients
50%; tunneling between rectum or kin
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;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Increased size during the day and valsalva means it is communicated with peritoneal cavity

36. prostate enlarged - nontender - no nodularity - elevated PSA
Urethral stricture; pelvic of urethral trauma
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

37. inhalation of hot air - steam - smoke in burn victim
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pure motor stroke; limited neurological dysfunction
Mammogram
Supraglottic edema; low threshold for intubation

38. How to differentiate communicative and non-communicative hydrocele
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Supraglottic edema; low threshold for intubation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Cystic scrotal fluid collection between parietal and visceral layers of testis

39. 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
If any compressive symptoms eg. dysphagia
Displaced ORIF ; nondisplaced sling immobilization
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

40. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

41. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Next best step surgery; not ultrasound
Unilateral vocal cord paralysis
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

42. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

43. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Mammogram
Tendons more likely
CRPS
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

44. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
4-6 weeks for noncontact sports and longer time for contact sports
Urethral stricture; pelvic of urethral trauma
Even after ochiopexy risk of ochiopexy higher then general population

45. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

46. dorsiflexion and planter flexion
Displaced ORIF ; nondisplaced sling immobilization
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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

47. cremasteric reflex
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

48. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

49. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pure motor stroke; limited neurological dysfunction

50. How to differentiate ACL and meniscus injury
Mammogram
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Seminomas
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