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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. management of stone 8-10mm
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
L5 to S2
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

2. beta HCG
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Progressive fibrosis of palmar fascia. etiololgy not known;
Seminomas

3. managment of animal bite in hands
Study showed no adverse effect; but they are contraindicated for PVD
Carpal tunnel syndrom
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;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

4. What are the common injuries from lightning?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
If any compressive symptoms eg. dysphagia
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

5. most frequent complication of TURP
Study showed no adverse effect; but they are contraindicated for PVD
Retrograde ejaculation
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

6. What time frame required for bone remodeling
Subphrenic abscess or other abdominal abscesses; order US or CT
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
10-12 months
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

7. 27 yo with scrotal mass; warm tender testes feel like bag of worms
CRPS
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Brardycardia - HTN - resp depression
Ispilateral hypoglossal nerve injury

8. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Less than 5mm
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

9. SAH due to posterior inferior cerebellar aneurysm
10-12 months
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Headache - ataxia - bulbar dysfunction

10. How to perform lachman test
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

11. several knee pain after being tackled in football game
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
MAT; medial meniscus injury; ACL and Tibial colateral ligament
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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;

12. stress 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Nonunion and avascular necrosis; fx can block blood supply;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
CRPS

14. xray finding of stress fx after 3-4w
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
When urethral catherization is unsuccessful
Compression stocking - weight reduction - leg elevation
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

15. cat/dog bites
CRPS
Amoxicillin-clavulanate
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
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. 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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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

17. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
S2-S4
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;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

18. antibiotics of acute cholecystitis
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

19. mx of stress fx
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Strok and traumatic brain injury
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

20. 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
Less than 5mm
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Headache - ataxia - bulbar dysfunction

21. Patient underwent CABG; postoperatively drowsy. most likely cause?
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
Elderly and critically ill patients
When urethral catherization is unsuccessful
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

22. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
Mammogram
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

23. What percent of anal abscess deveolop fisutula
Sphincter sparing surgery (local resection) - abdomnio perineal resection
50%; tunneling between rectum or kin
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Elderly and critically ill patients

24. ct scan; cystic lesion in head of pancreas; next step
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

25. Incidence of AF in CABG patient

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26. Complications of breast impant
Ampicillin sublactum - pipercillin - ceftriaxone and metro
CRPS
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

27. Valgus and Varus tests
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Dm neuropathy; stocking glove pattern

28. How to confirm dx of compartment syndrom
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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;
15-40%; self limiting;doesn't require tx

29. pregnant patient with asymptomatic gall stones
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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 gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

30. conservative Tx of varicose veins
Next best step surgery; not ultrasound
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Compression stocking - weight reduction - leg elevation
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

31. 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
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

32. diarrhoea 4-5 days after cholecystectomy
Twisting force with the foot fixed on the ground seen in football and basketball games;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
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
L5 to S2

33. menisci injury
When urethral catherization is unsuccessful
Ispilateral hypoglossal nerve injury
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Twisting force with the foot fixed on the ground seen in football and basketball games;

34. Can we use beta blocker for pvd?
Compression stocking - weight reduction - leg elevation
50%; tunneling between rectum or kin
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Study showed no adverse effect; but they are contraindicated for PVD

35. transrectal prostate biopsy
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;
Compression stocking - weight reduction - leg elevation
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

36. 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
ACL injury
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Seminomas

37. first line of management of PVD
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Strok and traumatic brain injury
CRPS

38. aspiration of breast cyst is bloody
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
When urethral catherization is unsuccessful
Meniscus injury; medial most common; pain/swelling; popping sensation
Mammogram

39. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Pure motor stroke; limited neurological dysfunction
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Subphrenic abscess or other abdominal abscesses; order US or CT
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

40. management of nondisplaced scaphoid fx
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

41. When to do surgery in undesceneded testis?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Meniscus injury; medial most common; pain/swelling; popping sensation
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

42. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

43. perioral numbness after parathyroidectomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Compression stocking - weight reduction - leg elevation
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

44. 3 mo with groin bulge; bulge appears when child cries
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

45. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
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

46. varicocele
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
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

47. dorsiflexion and planter flexion
Meniscus injury; medial most common; pain/swelling; popping sensation
Next best step surgery; not ultrasound
Displaced ORIF ; nondisplaced sling immobilization
L5 to S2

48. What is the strongest risk factor for male breast cancer
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Klinefelter syndrome; 50 fold increase;

49. most common complication of acute cholecystitis
Saline and silicone
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
If patient ambulatory - surgery and pain control; if not nonop mx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

50. inhalation of hot air - steam - smoke in burn victim
Abd pain and tenderness; bloody diarrhoea or hematochezia
Mammogram
Supraglottic edema; low threshold for intubation
Strok and traumatic brain injury