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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. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Subphrenic abscess or other abdominal abscesses; order US or CT
Meniscus injury; medial most common; pain/swelling; popping sensation
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy

2. aspiration of breast cyst is bloody
Mammogram
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Ispilateral hypoglossal nerve injury

3. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Meniscus injury; medial most common; pain/swelling; popping sensation

4. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If any compressive symptoms eg. dysphagia
Malignancy until proven otherwise
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. complications of TPN
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Unilateral vocal cord paralysis
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

6. how ABI help dx of PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Mammogram
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

7. first line of management of PVD
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Saline and silicone
Dm neuropathy; stocking glove pattern
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

8. conservative Tx of varicose veins
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Compression stocking - weight reduction - leg elevation
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

9. aspiration of breast cyst is nonbloody
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Progressive fibrosis of palmar fascia. etiololgy not known;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

10. cat/dog bites
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Amoxicillin-clavulanate

11. 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
When urethral catherization is unsuccessful
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Abd pain and tenderness; bloody diarrhoea or hematochezia

12. What is hungry bone syndrome?
Carpal tunnel syndrom
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
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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;

13. management of nondisplaced scaphoid fx
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Elderly and critically ill patients
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

14. How to differentiate communicative and non-communicative hydrocele
Dm neuropathy; stocking glove pattern
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports

15. clavicle fx
Amoxicillin-clavulanate
Dumping syndrome; small and frequent meals; no simple sugar
Displaced ORIF ; nondisplaced sling immobilization
24-48 hours of supportive therapy followed by cholecystectomy

16. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Strok and traumatic brain injury
10-12 months

17. What is prehn sign?
Less than 5mm
Pure motor stroke; limited neurological dysfunction
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;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

18. how hyperventilation lowers ICP
Low anterior resection and radio; add chemo if node positive
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;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

19. What types of breast implants are available
Saline and silicone
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
Displaced ORIF ; nondisplaced sling immobilization
50%; tunneling between rectum or kin

20. Tx of pulmonary contusion
L5 to S2
Check ET tube placement if correct needle decompresion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Displaced ORIF ; nondisplaced sling immobilization

21. management of gunshot wound
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
50%; tunneling between rectum or kin
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

22. most common complication of acute cholecystitis
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;
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

23. Why initial xrays are negative in scaphoid fx
Amoxicillin-clavulanate
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

24. lacerated wound in palmer surface of hand. what structure is injured?
Compression stocking - weight reduction - leg elevation
Tendons more likely
Abd pain and tenderness; bloody diarrhoea or hematochezia
If any compressive symptoms eg. dysphagia

25. Why ruq calcificaion is concerning
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
When urethral catherization is unsuccessful
Low anterior resection and radio; add chemo if node positive
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

26. How to confirm dx of compartment syndrom
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

27. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

28. severe pain in leg after MVC
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
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
Klinefelter syndrome; 50 fold increase;
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

29. several knee pain after being tackled in football game
Twisting force with the foot fixed on the ground seen in football and basketball games;
If patient ambulatory - surgery and pain control; if not nonop mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

30. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Compression stocking - weight reduction - leg elevation
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

31. When to stop raloxifene before surgery
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
S2-S4
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

32. inhalation of hot air - steam - smoke in burn victim
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Supraglottic edema; low threshold for intubation
Subphrenic abscess or other abdominal abscesses; order US or CT

33. Why varicocele more common in the left side
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
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;
L5 to S2
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

34. What percent of anal abscess deveolop fisutula
50%; tunneling between rectum or kin
10-12 months
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Elderly and critically ill patients

35. differential of ultrasound finding of breast mass
Dm neuropathy; stocking glove pattern
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
Ispilateral hypoglossal nerve injury
If any compressive symptoms eg. dysphagia

36. management of stone 8-10mm
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Seminomas
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

37. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dm neuropathy; stocking glove pattern
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

38. dorsiflexion and planter flexion
Strok and traumatic brain injury
4-6 weeks for noncontact sports and longer time for contact sports
L5 to S2
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

39. 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
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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;
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

40. diarrhoea after gastric bypass
SAH due to post communicating artery aneurysm;
Dumping syndrome; small and frequent meals; no simple sugar
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
Ispilateral hypoglossal nerve injury

41. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Study showed no adverse effect; but they are contraindicated for PVD
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Tendons more likely

42. midline neck swelling moves with protrusion of tongue
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
MAT; medial meniscus injury; ACL and Tibial colateral ligament

43. DD of acute scrotal pain
ACL injury
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;
Meniscus injury; medial most common; pain/swelling; popping sensation
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

44. pregnant patient with asymptomatic gall stones
Dumping syndrome; small and frequent meals; no simple sugar
Abd pain and tenderness; bloody diarrhoea or hematochezia
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

45. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Displaced ORIF ; nondisplaced sling immobilization
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

46. How to perform lachman test
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

47. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elderly and critically ill patients
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
Elevated non seminomas

48. When to do surgery in undesceneded testis?
CRPS
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
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

49. SOB - confusion - petechial rash after trauma - fracture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If any compressive symptoms eg. dysphagia
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Brardycardia - HTN - resp depression

50. 3 mo with groin bulge; bulge appears when child cries
Saline and silicone
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
50%; tunneling between rectum or kin
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal