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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. midline neck swelling moves with protrusion of tongue
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

2. How mcmurray manuver perform
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

3. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Klinefelter syndrome; 50 fold increase;

4. What time frame required for bone remodeling
Dm neuropathy; stocking glove pattern
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
10-12 months

5. How to confirm dx of compartment syndrom
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
15-40%; self limiting;doesn't require tx
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

6. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
SAH due to post communicating artery aneurysm;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

7. How to dx ACL tear?
Urethral stricture; pelvic of urethral trauma
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

8. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
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
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

9. first step for evaluation of testicular swelling
Dm neuropathy; stocking glove pattern
CRPS
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

10. recurrent laryngeal nerve injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Unilateral vocal cord paralysis
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
Saline and silicone

11. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

12. Dupuytren contracture
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Strok and traumatic brain injury
Progressive fibrosis of palmar fascia. etiololgy not known;
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

13. What is terrible triad
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

14. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

15. 3 mo with groin bulge; bulge appears when child cries
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Cystic scrotal fluid collection between parietal and visceral layers of testis
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

16. what size of ureteral stone for non op mx
Less than 5mm
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Ispilateral hypoglossal nerve injury

17. 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
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
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

18. how ABI help dx of PVD
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pure motor stroke; limited neurological dysfunction
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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

19. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
When urethral catherization is unsuccessful
L5 to S2
Mammogram

20. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Saline and silicone

21. What is most common lung injury after blunt chest trauma?
Retrograde ejaculation
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

22. varicocele
Pure motor stroke; limited neurological dysfunction
Dumping syndrome; small and frequent meals; no simple sugar
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

23. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
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
If any compressive symptoms eg. dysphagia
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

24. differential of ultrasound finding of breast mass
Check ET tube placement if correct needle decompresion
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;
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
Progressive fibrosis of palmar fascia. etiololgy not known;

25. aspiration of breast cyst is bloody
Progressive fibrosis of palmar fascia. etiololgy not known;
Mammogram
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

26. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Carpal tunnel syndrom
Strok and traumatic brain injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

27. What is cushing's triad
Epi and chest compressio for prolong period of time; atropine is given after epi;
4-6 weeks for noncontact sports and longer time for contact sports
Brardycardia - HTN - resp depression
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

28. Indication for bariatric surgery in obese patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Brardycardia - HTN - resp depression
Dumping syndrome; small and frequent meals; no simple sugar
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;

29. lacunar stroke
Pure motor stroke; limited neurological dysfunction
15-40%; self limiting;doesn't require tx
Low anterior resection and radio; add chemo if node positive
Nonunion and avascular necrosis; fx can block blood supply;

30. transrectal prostate biopsy
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Even after ochiopexy risk of ochiopexy higher then general population
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

31. When patient can go back to sports after clavicle fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
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
4-6 weeks for noncontact sports and longer time for contact sports

32. How varicocele causes testicular atrophy
If patient ambulatory - surgery and pain control; if not nonop mx
Strok and traumatic brain injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
MAT; medial meniscus injury; ACL and Tibial colateral ligament

33. When do we see complications due to hypophosphatemia
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Progressive fibrosis of palmar fascia. etiololgy not known;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;

34. xray finding of stress fx after 3-4w
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Next best step surgery; not ultrasound
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Elevated non seminomas

35. cremasteric reflex test?
Less than 5mm
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Next best step surgery; not ultrasound
If any compressive symptoms eg. dysphagia

36. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Ispilateral hypoglossal nerve injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate

37. management of nondisplaced scaphoid fx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

38. Valgus and Varus tests
Subphrenic abscess or other abdominal abscesses; order US or CT
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
ACL injury

39. When to stop raloxifene before surgery
Epi and chest compressio for prolong period of time; atropine is given after epi;
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
24-48 hours of supportive therapy followed by cholecystectomy

40. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Klinefelter syndrome; 50 fold increase;
Unilateral vocal cord paralysis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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

41. when scaphoid fx patient needs to be referred to orthopedic
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

42. types of hip fracture
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Meniscus injury; medial most common; pain/swelling; popping sensation
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

43. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;

44. beta hcg and AFP
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
SAH due to post communicating artery aneurysm;
Elevated non seminomas
Twisting force with the foot fixed on the ground seen in football and basketball games;

45. surgery for acute cholecystities
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
Cystic scrotal fluid collection between parietal and visceral layers of testis
24-48 hours of supportive therapy followed by cholecystectomy
Headache - ataxia - bulbar dysfunction

46. DD of acute scrotal pain
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
4-6 weeks for noncontact sports and longer time for contact sports
Headache - ataxia - bulbar dysfunction
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

47. contraindication of urethral catheterization
Elderly and critically ill patients
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Urethral stricture; pelvic of urethral trauma
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

48. swelling and tenderness in anterior part of knee
SAH due to post communicating artery aneurysm;
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
Patellar tendon tear; difficulty in extension
Twisting force with the foot fixed on the ground seen in football and basketball games;

49. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Cystic scrotal fluid collection between parietal and visceral layers of testis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

50. aspiration of breast cyst is nonbloody
Abd pain and tenderness; bloody diarrhoea or hematochezia
L5 to S2
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram