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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. DD of acute scrotal pain
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ampicillin sublactum - pipercillin - ceftriaxone and metro

2. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Displaced ORIF ; nondisplaced sling immobilization
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

3. management of gunshot wound
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
Check ET tube placement if correct needle decompresion
Compression stocking - weight reduction - leg elevation
Brardycardia - HTN - resp depression

4. dorsiflexion and planter flexion
L5 to S2
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Brardycardia - HTN - resp depression
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

5. ipsilateral deviation of tongue upon protrusion
CRPS
Headache - ataxia - bulbar dysfunction
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury

6. When do we see complications due to hypophosphatemia
Strok and traumatic brain injury
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Saline and silicone
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 to perform lachman test
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Less than 5mm

8. anal sphincter tone
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Elderly and critically ill patients
S2-S4

9. management of stone 8-10mm
If patient ambulatory - surgery and pain control; if not nonop mx
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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

10. When to stop raloxifene before surgery
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

11. What is hungry bone syndrome?
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;
Elderly and critically ill patients
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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

12. managment of animal bite in hands
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
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;
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

13. beta hcg and AFP
Elevated non seminomas
Check ET tube placement if correct needle decompresion
15-40%; self limiting;doesn't require tx
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

14. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Low anterior resection and radio; add chemo if node positive
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Brardycardia - HTN - resp depression
SAH due to post communicating artery aneurysm;

15. sudden onset of postoperative hyperglycemia when patient on TPN
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

16. beta HCG
Seminomas
Increased size during the day and valsalva means it is communicated with peritoneal cavity
If patient ambulatory - surgery and pain control; if not nonop mx
4-6 weeks for noncontact sports and longer time for contact sports

17. most common fx when falling on outsretched hand
Unilateral vocal cord paralysis
Tendons more likely
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

18. varicocele
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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
Tendons more likely

19. types of hip fracture
Brardycardia - HTN - resp depression
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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

20. Most common of sudden death due to steering wheel injury
Saline and silicone
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abd pain and tenderness; bloody diarrhoea or hematochezia

21. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

22. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
24-48 hours of supportive therapy followed by cholecystectomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

23. diarrhoea 4-5 days after cholecystectomy
Unilateral vocal cord paralysis
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

24. cat/dog bites
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Amoxicillin-clavulanate
ACL injury
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
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
Meniscus injury; medial most common; pain/swelling; popping sensation
Check ET tube placement if correct needle decompresion

26. contraindication of urethral catheterization
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Urethral stricture; pelvic of urethral trauma
SAH due to post communicating artery aneurysm;
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

27. management of hip fracture
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Amoxicillin-clavulanate
If patient ambulatory - surgery and pain control; if not nonop mx
Dumping syndrome; small and frequent meals; no simple sugar

28. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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;
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

29. lacunar stroke
Pure motor stroke; limited neurological dysfunction
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
Dm neuropathy; stocking glove pattern
Abd pain and tenderness; bloody diarrhoea or hematochezia

30. What is most common lung injury after blunt chest trauma?
Elderly and critically ill patients
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
Retrograde ejaculation
10-12 months

31. When to do surgery in undesceneded testis?
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

32. How to evaluate painless testicular swelling suspicious for cancer
Carpal tunnel syndrom
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
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;

33. aspiration of breast cyst is nonbloody
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
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
ACL 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

34. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Patellar tendon tear; difficulty in extension
Tendons more likely
Next best step surgery; not ultrasound

35. how hyperventilation lowers ICP
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

36. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Abd pain and tenderness; bloody diarrhoea or hematochezia

37. how ABI help dx of PVD
Nonunion and avascular necrosis; fx can block blood supply;
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Carpal tunnel syndrom
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

38. scrotal trauma
Next best step surgery; not ultrasound
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fx displace >1mm - nonunion during followup - osteonecrosis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

39. What is the contraindication of hyperventilation in inc ICP
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Strok and traumatic brain injury
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

40. Valgus and Varus tests
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

41. cremasteric reflex
S2-S4
Study showed no adverse effect; but they are contraindicated for PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

42. When goiter needs surgery
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
If any compressive symptoms eg. dysphagia

43. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Elevated non seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

44. Tx of pulmonary contusion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

45. painless testicular mass in young male
Even after ochiopexy risk of ochiopexy higher then general population
Malignancy until proven otherwise
ACL injury
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

46. How to differentiate communicative and non-communicative hydrocele
Meniscus injury; medial most common; pain/swelling; popping sensation
Nonunion and avascular necrosis; fx can block blood supply;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Displaced ORIF ; nondisplaced sling immobilization

47. Indication for bariatric surgery in obese patients
S2-S4
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

48. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Epi and chest compressio for prolong period of time; atropine is given after epi;
Saline and silicone

49. Dupuytren contracture
Pure motor stroke; limited neurological dysfunction
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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;
Progressive fibrosis of palmar fascia. etiololgy not known;

50. complication displaced or communited distal radial fx
Carpal tunnel syndrom
Urethral stricture; pelvic of urethral trauma
ACL injury
Scrotal ultrasound; cystic and fluid filled collections are noncancerous