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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. cremasteric reflex
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

2. Valgus and Varus tests
Twisting force with the foot fixed on the ground seen in football and basketball games;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

3. conservative Tx of varicose veins
Supraglottic edema; low threshold for intubation
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If any compressive symptoms eg. dysphagia
Compression stocking - weight reduction - leg elevation

4. scrotal trauma
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
Next best step surgery; not ultrasound
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
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

5. diarrhoea 4-5 days after cholecystectomy
Mammogram
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Patellar tendon tear; difficulty in extension
Low anterior resection and radio; add chemo if node positive

6. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Study showed no adverse effect; but they are contraindicated for PVD
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Cystic scrotal fluid collection between parietal and visceral layers of testis

7. differential of ultrasound finding of breast mass
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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

8. Incidence of AF in CABG patient

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9. How to dx ACL tear?
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

10. acalculus cholecystitis
Elderly and critically ill patients
Displaced ORIF ; nondisplaced sling immobilization
Meniscus injury; medial most common; pain/swelling; popping sensation
Headache - ataxia - bulbar dysfunction

11. Complications of breast impant
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Dumping syndrome; small and frequent meals; no simple sugar
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Ispilateral hypoglossal nerve injury

12. How to differentiate ACL and meniscus injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Carpal tunnel syndrom
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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

13. beta hcg and AFP
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevated non seminomas
Pure motor stroke; limited neurological dysfunction
Dumping syndrome; small and frequent meals; no simple sugar

14. pregnant patient with asymptomatic gall stones
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
If patient ambulatory - surgery and pain control; if not nonop mx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis

15. dumping syndrome after gastrectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Seminomas
50%; tunneling between rectum or kin

16. How to manage obesity
ACL injury
Headache - ataxia - bulbar dysfunction
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

17. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Unilateral vocal cord paralysis
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Nonunion and avascular necrosis; fx can block blood supply;

18. characteristics of ureteral stone?
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
50%; tunneling between rectum or kin
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

19. What is the strongest risk factor for male breast cancer
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Unilateral vocal cord paralysis
Klinefelter syndrome; 50 fold increase;
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. ipsilateral deviation of tongue upon protrusion
Urethral stricture; pelvic of urethral trauma
SAH due to post communicating artery aneurysm;
Ispilateral hypoglossal nerve injury
Less than 5mm

21. acute colonic ischemia
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Abd pain and tenderness; bloody diarrhoea or hematochezia
Check ET tube placement if correct needle decompresion
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

22. management of gunshot wound
Pure motor stroke; limited neurological dysfunction
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 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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

23. most common fx when falling on outsretched hand
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
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

24. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
S2-S4
Retrograde ejaculation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

25. What is hungry bone syndrome?
If any compressive symptoms eg. dysphagia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

26. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Malignancy until proven otherwise

27. management of nondisplaced scaphoid fx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

28. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Meniscus injury; medial most common; pain/swelling; popping sensation
4-6 weeks for noncontact sports and longer time for contact sports

29. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Headache - ataxia - bulbar dysfunction
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

30. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
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
Seminomas
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

31. beta HCG
Fx displace >1mm - nonunion during followup - osteonecrosis
Seminomas
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
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

32. mangement of localized lymphadenopathy
Epi and chest compressio for prolong period of time; atropine is given after epi;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Urethral stricture; pelvic of urethral trauma
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

33. 27 yo with scrotal mass; warm tender testes feel like bag of worms
24-48 hours of supportive therapy followed by cholecystectomy
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pure motor stroke; limited neurological dysfunction
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

34. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Seminomas

35. When goiter needs surgery
Retrograde ejaculation
Less than 5mm
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If any compressive symptoms eg. dysphagia

36. clavicle fx
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

37. suprapubic catheterization
Check ET tube placement if correct needle decompresion
When urethral catherization is unsuccessful
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;
Retrograde ejaculation

38. how ABI help dx of PVD
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Meniscus injury; medial most common; pain/swelling; popping sensation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
L5 to S2

39. xray finding of stress fx after 3-4w
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

40. What types of breast implants are available
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
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;
Saline and silicone
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

41. Why ruq calcificaion is concerning
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
Supraglottic edema; low threshold for intubation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

42. popping sensation; rapid onset of knee effusion. athelet
ACL 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
Low anterior resection and radio; add chemo if node positive
MAT; medial meniscus injury; ACL and Tibial colateral ligament

43. lacunar stroke
Subphrenic abscess or other abdominal abscesses; order US or CT
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Pure motor stroke; limited neurological dysfunction

44. most common complication of acute cholecystitis
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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

45. contraindication of urethral catheterization
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Urethral stricture; pelvic of urethral trauma
Malignancy until proven otherwise
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

46. what size of ureteral stone for non op mx
Less than 5mm
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
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

47. diarrhoea after gastric bypass
Ampicillin sublactum - pipercillin - ceftriaxone and metro
If patient ambulatory - surgery and pain control; if not nonop mx
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dumping syndrome; small and frequent meals; no simple sugar

48. Most common of sudden death due to steering wheel injury
S2-S4
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;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Ispilateral hypoglossal nerve injury

49. complications of TPN
Less than 5mm
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

50. varicocele
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Compression stocking - weight reduction - leg elevation