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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. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
If any compressive symptoms eg. dysphagia

2. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Low anterior resection and radio; add chemo if node positive
SAH due to post communicating artery aneurysm;
Malignancy until proven otherwise
50%; tunneling between rectum or kin

3. Complications of breast impant
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

4. What is terrible triad
Elevated non seminomas
Urethral stricture; pelvic of urethral trauma
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Abd pain and tenderness; bloody diarrhoea or hematochezia
Cystic scrotal fluid collection between parietal and visceral layers of testis
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

6. 3 mo with groin bulge; bulge appears when child cries
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

7. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Pure motor stroke; limited neurological dysfunction
CRPS

8. How varicocele causes testicular atrophy
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Next best step surgery; not ultrasound
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;
Supraglottic edema; low threshold for intubation

9. Can we use beta blocker for pvd?
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
Study showed no adverse effect; but they are contraindicated for PVD
Dumping syndrome; small and frequent meals; no simple sugar
Nonunion and avascular necrosis; fx can block blood supply;

10. painless testicular mass in young male
Malignancy until proven otherwise
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pure motor stroke; limited neurological dysfunction

11. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Check ET tube placement if correct needle decompresion
Strok and traumatic brain injury

12. What is prehn sign?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
L5 to S2
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
When urethral catherization is unsuccessful

13. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Displaced ORIF ; nondisplaced sling immobilization
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Check ET tube placement if correct needle decompresion
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

14. how ABI help dx of PVD
Progressive fibrosis of palmar fascia. etiololgy not known;
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;
SAH due to post communicating artery aneurysm;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

15. beta hcg and AFP
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Elevated non seminomas
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

16. Why varicocele more common in the left side
Epi and chest compressio for prolong period of time; atropine is given after epi;
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
ACL injury

17. perioral numbness after parathyroidectomy
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

18. Patient underwent CABG; postoperatively drowsy. most likely cause?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
Nonunion and avascular necrosis; fx can block blood supply;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

19. dorsiflexion and planter flexion
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
L5 to S2
10-12 months
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

20. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Fx displace >1mm - nonunion during followup - osteonecrosis
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

21. ipsilateral deviation of tongue upon protrusion
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;
Ispilateral hypoglossal nerve injury
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
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

22. types of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
Mammogram
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Elderly and critically ill patients

23. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Malignancy until proven otherwise

24. Incidence of AF in CABG patient

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25. management of hip fracture
Compression stocking - weight reduction - leg elevation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If patient ambulatory - surgery and pain control; if not nonop mx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

26. antibiotics of acute cholecystitis
Next best step surgery; not ultrasound
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Saline and silicone
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

27. clavicle fx
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;
L5 to S2
Displaced ORIF ; nondisplaced sling immobilization
Nonunion and avascular necrosis; fx can block blood supply;

28. acalculus cholecystitis
10-12 months
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Elderly and critically ill patients

29. What is most common lung injury after blunt chest trauma?
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

30. Dupuytren contracture
Epi and chest compressio for prolong period of time; atropine is given after epi;
Progressive fibrosis of palmar fascia. etiololgy not known;
Compression stocking - weight reduction - leg elevation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

31. What is the complications of undescended testis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Epi and chest compressio for prolong period of time; atropine is given after epi;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Even after ochiopexy risk of ochiopexy higher then general population

32. Tx of pulmonary contusion
SAH due to post communicating artery aneurysm;
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

33. management of gunshot wound
L5 to S2
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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

34. What types of breast implants are available
Saline and silicone
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
Elevated non seminomas
Sphincter sparing surgery (local resection) - abdomnio perineal resection

35. varicocele
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

36. lacunar stroke
50%; tunneling between rectum or kin
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Pure motor stroke; limited neurological dysfunction
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

37. How to manage a patient with asystole
Strok and traumatic brain injury
Epi and chest compressio for prolong period of time; atropine is given after epi;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Fx displace >1mm - nonunion during followup - osteonecrosis

38. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

39. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dm neuropathy; stocking glove pattern

40. severe pain in leg after MVC
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
When urethral catherization is unsuccessful
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

41. suprapubic catheterization
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
24-48 hours of supportive therapy followed by cholecystectomy
When urethral catherization is unsuccessful
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

42. mx of stress fx
Progressive fibrosis of palmar fascia. etiololgy not known;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

43. managment of animal bite in hands
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;
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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

44. dumping syndrome after gastrectomy
Amoxicillin-clavulanate
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

45. How to evaluate painless testicular swelling suspicious for cancer
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

46. When goiter needs surgery
If any compressive symptoms eg. dysphagia
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

47. diarrhoea 4-5 days after cholecystectomy
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
S2-S4
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

48. SOB - confusion - petechial rash after trauma - fracture
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

49. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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

50. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)