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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. Incidence of AF in CABG patient

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2. SOB - confusion - petechial rash after trauma - fracture
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Klinefelter syndrome; 50 fold increase;

3. 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
Saline and silicone
S2-S4
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

4. cremasteric reflex test?
Patellar tendon tear; difficulty in extension
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
CRPS
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

5. varicocele
50%; tunneling between rectum or kin
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Progressive fibrosis of palmar fascia. etiololgy not known;

6. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Brardycardia - HTN - resp depression

7. transrectal prostate biopsy
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 prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

8. 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
Dumping syndrome; small and frequent meals; no simple sugar
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

9. How to confirm achiles tendon rupture
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
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
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Cystic scrotal fluid collection between parietal and visceral layers of testis

10. management of stone 8-10mm
Ispilateral hypoglossal nerve injury
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Amoxicillin-clavulanate
Twisting force with the foot fixed on the ground seen in football and basketball games;

11. How to differentiate communicative and non-communicative hydrocele
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;
When urethral catherization is unsuccessful
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Increased size during the day and valsalva means it is communicated with peritoneal cavity

12. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Nonunion and avascular necrosis; fx can block blood supply;

13. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Dumping syndrome; small and frequent meals; no simple sugar

14. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If patient ambulatory - surgery and pain control; if not nonop mx
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

15. painless testicular mass in young male
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Malignancy until proven otherwise
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Supraglottic edema; low threshold for intubation

16. When goiter needs surgery
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
Unilateral vocal cord paralysis
If any compressive symptoms eg. dysphagia

17. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Twisting force with the foot fixed on the ground seen in football and basketball games;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

18. midline neck swelling moves with protrusion of tongue
4-6 weeks for noncontact sports and longer time for contact sports
Strok and traumatic brain injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
If any compressive symptoms eg. dysphagia

19. What is prehn sign?
10-12 months
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Brardycardia - HTN - resp depression
Progressive fibrosis of palmar fascia. etiololgy not known;

20. How to manage a patient with asystole
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

21. Can we use beta blocker for pvd?
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
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
Study showed no adverse effect; but they are contraindicated for PVD

22. dorsiflexion and planter flexion
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
L5 to S2
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

23. xray finding of stress fx after 3-4w
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

24. anal sphincter tone
S2-S4
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
Elderly and critically ill patients
Supraglottic edema; low threshold for intubation

25. lacerated wound in palmer surface of hand. what structure is injured?
Tendons more likely
Check ET tube placement if correct needle decompresion
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

26. aspiration of breast cyst is nonbloody
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 there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Meniscus injury; medial most common; pain/swelling; popping sensation
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

27. when scaphoid fx patient needs to be referred to orthopedic
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;
50%; tunneling between rectum or kin
Fx displace >1mm - nonunion during followup - osteonecrosis

28. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Supraglottic edema; low threshold for intubation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

29. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Ispilateral hypoglossal nerve injury

30. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
10-12 months
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Ispilateral hypoglossal nerve injury
Cystic scrotal fluid collection between parietal and visceral layers of testis

31. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Low anterior resection and radio; add chemo if node positive
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

32. sudden onset of postoperative hyperglycemia when patient on TPN
Even after ochiopexy risk of ochiopexy higher then general population
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
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
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;

33. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Seminomas
CRPS
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
SAH due to post communicating artery aneurysm;

34. differential of ultrasound finding of breast mass
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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
L5 to S2
Ampicillin sublactum - pipercillin - ceftriaxone and metro

35. How to dx ACL tear?
Unilateral vocal cord paralysis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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

36. acute colonic ischemia
Fx displace >1mm - nonunion during followup - osteonecrosis
Next best step surgery; not ultrasound
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Abd pain and tenderness; bloody diarrhoea or hematochezia

37. popping sensation; rapid onset of knee effusion. athelet
ACL injury
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Klinefelter syndrome; 50 fold increase;
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

38. What is the complications of undescended testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Brardycardia - HTN - resp depression
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;
Even after ochiopexy risk of ochiopexy higher then general population

39. aspiration of breast cyst is bloody
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Mammogram
Compression stocking - weight reduction - leg elevation
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

40. Why initial xrays are negative in scaphoid fx
Urethral stricture; pelvic of urethral trauma
Progressive fibrosis of palmar fascia. etiololgy not known;
ACL injury
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

41. management of nondisplaced scaphoid fx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

42. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Ispilateral hypoglossal nerve injury
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

43. varicose veins with ulcer - bleeding and thrombophlebitits
Amoxicillin-clavulanate
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;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

44. How mcmurray manuver perform
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
Headache - ataxia - bulbar dysfunction
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Malignancy until proven otherwise

45. Valgus and Varus tests
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;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Ampicillin sublactum - pipercillin - ceftriaxone and metro
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

46. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Seminomas
Unilateral vocal cord paralysis

47. DD of acute scrotal pain
24-48 hours of supportive therapy followed by cholecystectomy
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Ispilateral hypoglossal nerve injury
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

48. What percent of anal abscess deveolop fisutula
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Even after ochiopexy risk of ochiopexy higher then general population
10-12 months
50%; tunneling between rectum or kin

49. bilateral symmetric reduction in perception of vibration - pain and temperature; ED and absent cremastieric reflex
Dm neuropathy; stocking glove pattern
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

50. acalculus cholecystitis
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Malignancy until proven otherwise
Elderly and critically ill patients
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery