Test your basic knowledge |

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. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Epi and chest compressio for prolong period of time; atropine is given after epi;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Seminomas

2. what size of ureteral stone for non op mx
Retrograde ejaculation
Less than 5mm
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

3. 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
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

4. What percent of anal abscess deveolop fisutula
Headache - ataxia - bulbar dysfunction
Pt with severe hypercalcemia and hyperparathyroidism underwent parathyroid removal; then sudden withdrawn of PTH causing an influx of ca from circulation to bone; developing severe hypocalcemia; devleoped 2-3 days after surgery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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

5. stress fx
MAT; medial meniscus injury; ACL and Tibial colateral ligament
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Twisting force with the foot fixed on the ground seen in football and basketball games;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

6. How to perform lachman test
Elevated non seminomas
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Elderly and critically ill patients

7. When do we see complications due to hypophosphatemia
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
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;
If any compressive symptoms eg. dysphagia
Pure motor stroke; limited neurological dysfunction

8. What is hydrocele?
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Unilateral vocal cord paralysis
Cystic scrotal fluid collection between parietal and visceral layers of testis
Dm neuropathy; stocking glove pattern

9. management of nondisplaced scaphoid fx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

10. When to stop raloxifene before surgery
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Carpal tunnel syndrom
When urethral catherization is unsuccessful
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

11. What are the common injuries from lightning?
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

12. diarrhoea after gastric bypass
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dumping syndrome; small and frequent meals; no simple sugar
Seminomas
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

13. How to dx ACL tear?
Increased size during the day and valsalva means it is communicated with peritoneal cavity
CRPS
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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

14. midline neck swelling moves with protrusion of tongue
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
If patient ambulatory - surgery and pain control; if not nonop mx
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

15. beta hcg and AFP
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
50%; tunneling between rectum or kin
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Elevated non seminomas

16. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
If patient ambulatory - surgery and pain control; if not nonop mx
Brardycardia - HTN - resp depression
CRPS

17. inhalation of hot air - steam - smoke in burn victim
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
Supraglottic edema; low threshold for intubation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Brardycardia - HTN - resp depression

18. when scaphoid fx patient needs to be referred to orthopedic
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Fx displace >1mm - nonunion during followup - osteonecrosis

19. Patient underwent CABG; postoperatively drowsy. most likely cause?
Strok and traumatic brain 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;
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
Tendons more likely

20. contraindication of urethral catheterization
Retrograde ejaculation
Urethral stricture; pelvic of urethral trauma
Malignancy until proven otherwise
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

21. management of gunshot wound
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;
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;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

22. When to do surgery in undesceneded testis?
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Pure motor stroke; limited neurological dysfunction

23. management of stone 8-10mm
SAH due to post communicating artery aneurysm;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

24. severe pain in leg after MVC
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
50%; tunneling between rectum or kin
Brardycardia - HTN - resp depression
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

25. Most common of sudden death due to steering wheel injury
Saline and silicone
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

26. anal sphincter tone
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
S2-S4
4-6 weeks for noncontact sports and longer time for contact sports
Twisting force with the foot fixed on the ground seen in football and basketball games;

27. recurrent laryngeal nerve injury
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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;
Unilateral vocal cord paralysis

28. What is cushing's triad
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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;
Brardycardia - HTN - resp depression
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

29. How to confirm dx of compartment syndrom
Ispilateral hypoglossal nerve injury
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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)

30. lacerated wound in palmer surface of hand. what structure is injured?
Pure motor stroke; limited neurological dysfunction
Strok and traumatic brain injury
Tendons more likely
24-48 hours of supportive therapy followed by cholecystectomy

31. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
Low anterior resection and radio; add chemo if node positive
SAH due to post communicating artery aneurysm;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

32. How to differentiate communicative and non-communicative hydrocele
Mammogram
Elderly and critically ill patients
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity

33. ipsilateral deviation of tongue upon protrusion
Klinefelter syndrome; 50 fold increase;
Cystic scrotal fluid collection between parietal and visceral layers of testis
Ispilateral hypoglossal nerve injury
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

34. How to manage a patient with asystole
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Epi and chest compressio for prolong period of time; atropine is given after epi;
Headache - ataxia - bulbar dysfunction
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

35. How mcmurray manuver perform
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
ACL injury
Retrograde ejaculation

36. cremasteric reflex test?
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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

37. aspiration of breast cyst is bloody
Mammogram
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
When urethral catherization is unsuccessful
Urethral stricture; pelvic of urethral trauma

38. acalculus cholecystitis
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Elderly and critically ill patients
Displaced ORIF ; nondisplaced sling immobilization
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

39. several knee pain after being tackled in football game
Pure motor stroke; limited neurological dysfunction
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

40. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Twisting force with the foot fixed on the ground seen in football and basketball games;

41. 3 mo with groin bulge; bulge appears when child cries
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
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
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

42. 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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture 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;

43. sudden onset of postoperative hyperglycemia when patient on TPN
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Subphrenic abscess or other abdominal abscesses; order US or CT

44. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Headache - ataxia - bulbar dysfunction
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;
Urethral stricture; pelvic of urethral trauma
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

45. What types of breast implants are available
Saline and silicone
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Brardycardia - HTN - resp depression
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

46. pregnant patient with asymptomatic gall stones
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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

47. complications of TPN
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Saline and silicone
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

48. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
When urethral catherization is unsuccessful
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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;

49. What is prehn sign?
Klinefelter syndrome; 50 fold increase;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

50. cremasteric reflex
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
S2-S4
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position