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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. What is cushing's triad
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Brardycardia - HTN - resp depression

2. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Next best step surgery; not ultrasound
Dm neuropathy; stocking glove pattern

3. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous 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;
Seminomas
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

4. How to dx ACL tear?
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Low anterior resection and radio; add chemo if node positive
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

5. first step for evaluation of testicular swelling
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Check ET tube placement if correct needle decompresion

6. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cystic scrotal fluid collection between parietal and visceral layers of testis

7. How to confirm achiles tendon rupture
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Patellar tendon tear; difficulty in extension
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
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

8. sudden onset of postoperative hyperglycemia when patient on TPN
Fx displace >1mm - nonunion during followup - osteonecrosis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound 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

9. anal sphincter tone
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
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
S2-S4

10. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

11. management of stone 8-10mm
Low anterior resection and radio; add chemo if node positive
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
CRPS
Displaced ORIF ; nondisplaced sling immobilization

12. cremasteric reflex
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

13. Valgus and Varus tests
Displaced ORIF ; nondisplaced sling immobilization
Ampicillin sublactum - pipercillin - ceftriaxone and metro
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

14. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
4-6 weeks for noncontact sports and longer time for contact sports
Study showed no adverse effect; but they are contraindicated for PVD
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

15. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Progressive fibrosis of palmar fascia. etiololgy not known;
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;

16. What is the contraindication of hyperventilation in inc ICP
Meniscus injury; medial most common; pain/swelling; popping sensation
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;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Strok and traumatic brain injury

17. DD of acute scrotal pain
Progressive fibrosis of palmar fascia. etiololgy not known;
ACL injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

18. What is hungry bone syndrome?
Check ET tube placement if correct needle decompresion
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
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Tendons more likely

19. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
L5 to S2
Subphrenic abscess or other abdominal abscesses; order US or CT
When urethral catherization is unsuccessful
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

20. what size of ureteral stone for non op mx
Less than 5mm
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Increased size during the day and valsalva means it is communicated with peritoneal cavity

21. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Unilateral vocal cord paralysis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
50%; tunneling between rectum or kin

22. most frequent complication of TURP
Retrograde ejaculation
Progressive fibrosis of palmar fascia. etiololgy not known;
Headache - ataxia - bulbar dysfunction
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

23. beta HCG
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
Seminomas
Abd pain and tenderness; bloody diarrhoea or hematochezia
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

24. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Ispilateral hypoglossal nerve injury
Progressive fibrosis of palmar fascia. etiololgy not known;

25. When to stop raloxifene before surgery
Carpal tunnel syndrom
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
10-12 months
Klinefelter syndrome; 50 fold increase;

26. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If patient ambulatory - surgery and pain control; if not nonop mx
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;
Brardycardia - HTN - resp depression

27. when scaphoid fx patient needs to be referred to orthopedic
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Fx displace >1mm - nonunion during followup - osteonecrosis
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

28. differential of ultrasound finding of breast mass
Pure motor stroke; limited neurological dysfunction
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

29. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
SAH due to post communicating artery aneurysm;
Progressive fibrosis of palmar fascia. etiololgy not known;

30. varicose veins with ulcer - bleeding and thrombophlebitits
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Sphincter sparing surgery (local resection) - abdomnio perineal resection

31. How to differentiate ACL and meniscus injury
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
10-12 months
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

32. prostate enlarged - nontender - no nodularity - elevated PSA
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
4-6 weeks for noncontact sports and longer time for contact sports
Ampicillin sublactum - pipercillin - ceftriaxone and metro

33. how ABI help dx of PVD
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Elevated non seminomas
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

34. diarrhoea after gastric bypass
Brardycardia - HTN - resp depression
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 patient ambulatory - surgery and pain control; if not nonop mx
Dumping syndrome; small and frequent meals; no simple sugar

35. What is the complications of undescended testis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Meniscus injury; medial most common; pain/swelling; popping sensation
Even after ochiopexy risk of ochiopexy higher then general population
Low anterior resection and radio; add chemo if node positive

36. mx of stress fx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
15-40%; self limiting;doesn't require tx

37. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
CRPS
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;
Dumping syndrome; small and frequent meals; no simple sugar

38. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Epi and chest compressio for prolong period of time; atropine is given after epi;
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. suprapubic catheterization
When urethral catherization is unsuccessful
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Low anterior resection and radio; add chemo if node positive
Unilateral vocal cord paralysis

40. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

41. Why varicocele more common in the left side
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
L5 to S2
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

42. What are the common injuries from lightning?
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

43. When do we see complications due to hypophosphatemia
Unilateral vocal cord paralysis
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;
Check ET tube placement if correct needle decompresion
L5 to S2

44. How varicocele causes testicular atrophy
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
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

45. 3 mo with groin bulge; bulge appears when child cries
Seminomas
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Study showed no adverse effect; but they are contraindicated for PVD

46. What is prehn sign?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

47. management of gunshot wound
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

48. How to evaluate painless testicular swelling suspicious for cancer
If any compressive symptoms eg. dysphagia
Retrograde ejaculation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

49. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
S2-S4
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
CRPS
Meniscus injury; medial most common; pain/swelling; popping sensation

50. types of hip fracture
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;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Even after ochiopexy risk of ochiopexy higher then general population
Dumping syndrome; small and frequent meals; no simple sugar