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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. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Dumping syndrome; small and frequent meals; no simple sugar
Less than 5mm
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

2. When patient can go back to sports after clavicle fx
Pure motor stroke; limited neurological dysfunction
4-6 weeks for noncontact sports and longer time for contact sports
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

3. What is the contraindication of hyperventilation in inc ICP
Subphrenic abscess or other abdominal abscesses; order US or CT
Saline and silicone
If patient ambulatory - surgery and pain control; if not nonop mx
Strok and traumatic brain injury

4. painless testicular mass in young male
50%; tunneling between rectum or kin
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
L5 to S2
Malignancy until proven otherwise

5. contraindication of urethral catheterization
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Displaced ORIF ; nondisplaced sling immobilization
Urethral stricture; pelvic of urethral trauma

6. cat/dog bites
Amoxicillin-clavulanate
Twisting force with the foot fixed on the ground seen in football and basketball games;
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
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

7. most common fx when falling on outsretched hand
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
Urethral stricture; pelvic of urethral trauma
Retrograde ejaculation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

8. most common complication of acute cholecystitis
Twisting force with the foot fixed on the ground seen in football and basketball games;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
SAH due to post communicating artery aneurysm;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

9. severe pain in leg after MVC
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;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Displaced ORIF ; nondisplaced sling immobilization
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

10. What is most common lung injury after blunt chest trauma?
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
ACL injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

11. varicocele
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Urethral stricture; pelvic of urethral trauma
Low anterior resection and radio; add chemo if node positive
Malignancy until proven otherwise

12. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Fx displace >1mm - nonunion during followup - osteonecrosis
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

13. clavicle fx
Klinefelter syndrome; 50 fold increase;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Displaced ORIF ; nondisplaced sling immobilization

14. Valgus and Varus tests
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Urethral stricture; pelvic of urethral trauma
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

15. What is hydrocele?
15-40%; self limiting;doesn't require tx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Carpal tunnel syndrom
Cystic scrotal fluid collection between parietal and visceral layers of testis

16. Why right varicocele is more concerning?

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17. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Progressive fibrosis of palmar fascia. etiololgy not known;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

18. What is terrible triad
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
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Saline and silicone
CRPS

19. Why varicocele more common in the left side
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;
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
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

20. What are the common injuries from lightning?
Dumping syndrome; small and frequent meals; no simple sugar
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
15-40%; self limiting;doesn't require tx
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

21. when scaphoid fx patient needs to be referred to orthopedic
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
When urethral catherization is unsuccessful
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Fx displace >1mm - nonunion during followup - osteonecrosis

22. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

23. dorsiflexion and planter flexion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
L5 to S2
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

24. Why ruq calcificaion is concerning
Elderly and critically ill patients
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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

26. How to perform lachman test
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Ispilateral hypoglossal nerve injury
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

27. ipsilateral deviation of tongue upon protrusion
Subphrenic abscess or other abdominal abscesses; order US or CT
Ispilateral hypoglossal nerve injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

28. scrotal trauma
Low anterior resection and radio; add chemo if node positive
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
S2-S4
Next best step surgery; not ultrasound

29. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Cystic scrotal fluid collection between parietal and visceral layers of testis
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

30. What is hungry bone syndrome?
Nonunion and avascular necrosis; fx can block blood supply;
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
50%; tunneling between rectum or kin
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

31. aspiration of breast cyst is bloody
Mammogram
15-40%; self limiting;doesn't require tx
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

32. What types of breast implants are available
Saline and silicone
If any compressive symptoms eg. dysphagia
50%; tunneling between rectum or kin
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

33. anal sphincter tone
S2-S4
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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

34. mx of stress fx
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
Ispilateral hypoglossal nerve injury
CRPS
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

35. acalculus cholecystitis
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;
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
Elderly and critically ill patients
Klinefelter syndrome; 50 fold increase;

36. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Ispilateral hypoglossal nerve injury
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Retrograde ejaculation

37. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
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

38. 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
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Low anterior resection and radio; add chemo if node positive
If patient ambulatory - surgery and pain control; if not nonop mx

39. beta HCG
Saline and silicone
Check ET tube placement if correct needle decompresion
Seminomas
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

40. management of stone 8-10mm
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

41. varicose veins with ulcer - bleeding and thrombophlebitits
Compression stocking - weight reduction - leg elevation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Seminomas
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

42. Tx of proximal non metastatic rectal ca
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Patellar tendon tear; difficulty in extension
Low anterior resection and radio; add chemo if node positive

43. When goiter needs surgery
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
If any compressive symptoms eg. dysphagia
Urethral stricture; pelvic of urethral trauma
Patellar tendon tear; difficulty in extension

44. What is the complications of undescended testis
Even after ochiopexy risk of ochiopexy higher then general population
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

45. 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
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Next best step surgery; not ultrasound
50%; tunneling between rectum or kin

46. Why initial xrays are negative in scaphoid fx
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
Dumping syndrome; small and frequent meals; no simple sugar
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
24-48 hours of supportive therapy followed by cholecystectomy

47. how hyperventilation lowers ICP
MAT; medial meniscus injury; ACL and Tibial colateral ligament
ACL injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Seminomas

48. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Subphrenic abscess or other abdominal abscesses; order US or CT

49. management of hip fracture
Retrograde ejaculation
If patient ambulatory - surgery and pain control; if not nonop mx
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
S2-S4

50. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
SAH due to post communicating artery aneurysm;
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
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