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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. mx of stress fx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
10-12 months
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

2. anal sphincter tone
S2-S4
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Fx displace >1mm - nonunion during followup - osteonecrosis
Study showed no adverse effect; but they are contraindicated for PVD

3. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
If any compressive symptoms eg. dysphagia
Subphrenic abscess or other abdominal abscesses; order US or CT
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

4. perioral numbness after parathyroidectomy
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

5. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Brardycardia - HTN - resp depression
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

6. Indication for bariatric surgery in obese patients
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;
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

7. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Less than 5mm
L5 to S2

8. several knee pain after being tackled in football game
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Unilateral vocal cord paralysis
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Urethral stricture; pelvic of urethral trauma

9. Why ruq calcificaion is concerning
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

10. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
10-12 months
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

11. cat/dog bites
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Compression stocking - weight reduction - leg elevation
10-12 months
Amoxicillin-clavulanate

12. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Cystic scrotal fluid collection between parietal and visceral layers of testis
4-6 weeks for noncontact sports and longer time for contact sports
Patellar tendon tear; difficulty in extension
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

13. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;

14. What types of breast implants are available
Saline and silicone
Klinefelter syndrome; 50 fold increase;
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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

15. most frequent complication of TURP
24-48 hours of supportive therapy followed by cholecystectomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
50%; tunneling between rectum or kin
Retrograde ejaculation

16. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Seminomas
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

17. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Next best step surgery; not ultrasound
4-6 weeks for noncontact sports and longer time for contact sports
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

18. ct scan; cystic lesion in head of pancreas; next step
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

19. What is cushing's triad
Brardycardia - HTN - resp depression
Saline and silicone
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

20. Most common of sudden death due to steering wheel injury
When urethral catherization is unsuccessful
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Meniscus injury; medial most common; pain/swelling; popping sensation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

21. management of nondisplaced scaphoid fx
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Supraglottic edema; low threshold for intubation
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

22. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
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
Nonunion and avascular necrosis; fx can block blood supply;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

23. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Next best step surgery; not ultrasound
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Cystic scrotal fluid collection between parietal and visceral layers of testis
Increased size during the day and valsalva means it is communicated with peritoneal cavity

24. Valgus and Varus tests
Unilateral vocal cord paralysis
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Nonunion and avascular necrosis; fx can block blood supply;
Elderly and critically ill patients

25. dorsiflexion and planter flexion
L5 to S2
Elevated non seminomas
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

26. acalculus cholecystitis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Elderly and critically ill patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before 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;

27. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
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

28. first step for evaluation of testicular swelling
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sphincter sparing surgery (local resection) - abdomnio perineal resection
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

29. How to dx ACL tear?
L5 to S2
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
15-40%; self limiting;doesn't require tx
Low anterior resection and radio; add chemo if node positive

30. when patient with severe lung disease have C02 retention
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
Next best step surgery; not ultrasound
Ispilateral hypoglossal nerve injury
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

31. When to stop raloxifene before surgery
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Brardycardia - HTN - resp depression
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

32. How to confirm dx of compartment syndrom
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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

33. management of hip fracture
Saline and silicone
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If patient ambulatory - surgery and pain control; if not nonop mx
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

34. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
CRPS
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Saline and silicone
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

35. menisci injury
Supraglottic edema; low threshold for intubation
Twisting force with the foot fixed on the ground seen in football and basketball games;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

36. sudden onset of postoperative hyperglycemia when patient on TPN
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
When urethral catherization is unsuccessful
Seminomas
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

37. beta HCG
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Epi and chest compressio for prolong period of time; atropine is given after epi;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Seminomas

38. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
CRPS
Abd pain and tenderness; bloody diarrhoea or hematochezia

39. SOB - confusion - petechial rash after trauma - fracture
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

40. suprapubic catheterization
When urethral catherization is unsuccessful
Dumping syndrome; small and frequent meals; no simple sugar
Meniscus injury; medial most common; pain/swelling; popping sensation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

41. 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
Amoxicillin-clavulanate
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

42. complication displaced or communited distal radial fx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
15-40%; self limiting;doesn't require tx
Carpal tunnel syndrom

43. What is the complications of undescended testis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Even after ochiopexy risk of ochiopexy higher then general population
Displaced ORIF ; nondisplaced sling immobilization
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

44. how ABI help dx of PVD
Elevated non seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Amoxicillin-clavulanate

45. When goiter needs surgery
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports
If any compressive symptoms eg. dysphagia
When urethral catherization is unsuccessful

46. Why initial xrays are negative in scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
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
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

47. differential of ultrasound finding of breast mass
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

48. How to confirm achiles tendon rupture
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis

49. midline neck swelling moves with protrusion of tongue
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
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
Dumping syndrome; small and frequent meals; no simple sugar
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

50. Tx of pulmonary contusion
Saline and silicone
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case