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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. several knee pain after being tackled in football game
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
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
Check ET tube placement if correct needle decompresion
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

2. Can we use beta blocker for pvd?
Study showed no adverse effect; but they are contraindicated for PVD
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;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

3. scrotal trauma
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;
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;
Next best step surgery; not ultrasound
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

4. How to perform lachman test
4-6 weeks for noncontact sports and longer time for contact sports
Dm neuropathy; stocking glove pattern
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;

5. Indication for bariatric surgery in obese patients
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
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;

6. DD of acute scrotal pain
Headache - ataxia - bulbar dysfunction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Subphrenic abscess or other abdominal abscesses; order US or CT

7. menisci injury
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Twisting force with the foot fixed on the ground seen in football and basketball games;

8. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Supraglottic edema; low threshold for intubation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

9. characteristics of ureteral stone?
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
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
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

10. When to stop raloxifene before surgery
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

11. most common fx when falling on outsretched hand
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

12. How to confirm dx of compartment syndrom
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Check ET tube placement if correct needle decompresion

13. What is the strongest risk factor for male breast cancer
Brardycardia - HTN - resp depression
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
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;
Klinefelter syndrome; 50 fold increase;

14. What is hungry bone syndrome?
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
4-6 weeks for noncontact sports and longer time for contact sports
Less than 5mm
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

15. cremasteric reflex
Mammogram
Pure motor stroke; limited neurological dysfunction
Ispilateral hypoglossal nerve injury
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction

16. prostate enlarged - nontender - no nodularity - elevated PSA
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Nonunion and avascular necrosis; fx can block blood supply;

17. clavicle fx
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Displaced ORIF ; nondisplaced sling immobilization
10-12 months

18. Why right varicocele is more concerning?

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19. cat/dog bites
Carpal tunnel syndrom
Amoxicillin-clavulanate
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Next best step surgery; not ultrasound

20. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
L5 to S2

21. complication displaced or communited distal radial fx
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
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;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Carpal tunnel syndrom

22. What types of breast implants are available
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Saline and silicone
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

23. How to evaluate painless testicular swelling suspicious for cancer
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Pure motor stroke; limited neurological dysfunction
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

24. When do we see complications due to hypophosphatemia
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;
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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;
Ampicillin sublactum - pipercillin - ceftriaxone and metro

25. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Meniscus injury; medial most common; pain/swelling; popping sensation
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
Malignancy until proven otherwise

26. conservative Tx of varicose veins
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Compression stocking - weight reduction - leg elevation
L5 to S2

27. complications of TPN
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Nonunion and avascular necrosis; fx can block blood supply;
When urethral catherization is unsuccessful

28. What time frame required for bone remodeling
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
10-12 months
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

29. lacerated wound in palmer surface of hand. what structure is injured?
S2-S4
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Tendons more likely
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

30. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Subphrenic abscess or other abdominal abscesses; order US or CT
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

31. 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
50%; tunneling between rectum or kin
Even after ochiopexy risk of ochiopexy higher then general population
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

32. When patient can go back to sports after clavicle fx
4-6 weeks for noncontact sports and longer time for contact sports
Less than 5mm
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
Fx displace >1mm - nonunion during followup - osteonecrosis

33. transrectal prostate biopsy
Malignancy until proven otherwise
Saline and silicone
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

34. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
Fx displace >1mm - nonunion during followup - osteonecrosis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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;

35. How to differentiate communicative and non-communicative hydrocele
Displaced ORIF ; nondisplaced sling immobilization
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Fx displace >1mm - nonunion during followup - osteonecrosis
Next best step surgery; not ultrasound

36. When goiter needs surgery
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If any compressive symptoms eg. dysphagia
Cystic scrotal fluid collection between parietal and visceral layers of testis

37. anal sphincter tone
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Mammogram
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
S2-S4

38. Most common of sudden death due to steering wheel injury
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
ACL injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

39. Incidence of AF in CABG patient

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40. midline neck swelling moves with protrusion of tongue
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
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;
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
ACL injury

41. antibiotics of acute cholecystitis
Urethral stricture; pelvic of urethral trauma
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Saline and silicone
Ampicillin sublactum - pipercillin - ceftriaxone and metro

42. stress fx
Supraglottic edema; low threshold for intubation
Displaced ORIF ; nondisplaced sling immobilization
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

43. Complications of breast impant
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Ispilateral hypoglossal nerve injury
15-40%; self limiting;doesn't require tx

44. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;

45. 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
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Unilateral vocal cord paralysis

46. popping sensation; rapid onset of knee effusion. athelet
Ampicillin sublactum - pipercillin - ceftriaxone and metro
ACL injury
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Carpal tunnel syndrom

47. How to manage a patient with asystole
Epi and chest compressio for prolong period of time; atropine is given after epi;
Less than 5mm
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
If any compressive symptoms eg. dysphagia

48. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

49. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
Retrograde ejaculation
24-48 hours of supportive therapy followed by cholecystectomy
If patient ambulatory - surgery and pain control; if not nonop mx

50. What is the contraindication of hyperventilation in inc ICP
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Strok and traumatic brain injury
Elevated non seminomas