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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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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. aspiration of breast cyst is bloody
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Less than 5mm
Mammogram

2. How to manage obesity
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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

3. What is most common lung injury after blunt chest trauma?
CRPS
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
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
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

4. midline neck swelling moves with protrusion of tongue
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Strok and traumatic brain injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

5. Why varicocele more common in the left side
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Increased size during the day and valsalva means it is communicated with peritoneal cavity
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

6. What is hungry bone syndrome?
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
ACL injury
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

7. dumping syndrome after gastrectomy
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Amoxicillin-clavulanate
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

8. 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;
Nonunion and avascular necrosis; fx can block blood supply;
SAH due to post communicating artery aneurysm;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

9. ipsilateral deviation of tongue upon protrusion
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Ispilateral hypoglossal nerve injury

10. What types of breast implants are available
Saline and silicone
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
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

11. mx of stress fx
Abd pain and tenderness; bloody diarrhoea or hematochezia
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
4-6 weeks for noncontact sports and longer time for contact sports
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

12. What is cushing's triad
Compression stocking - weight reduction - leg elevation
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Amoxicillin-clavulanate
Brardycardia - HTN - resp depression

13. acute colonic ischemia
Compression stocking - weight reduction - leg elevation
Meniscus injury; medial most common; pain/swelling; popping sensation
Abd pain and tenderness; bloody diarrhoea or hematochezia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

14. aspiration of breast cyst is nonbloody
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
If any compressive symptoms eg. dysphagia
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

15. managment of animal bite in hands
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
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
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;

16. dorsiflexion and planter flexion
Dm neuropathy; stocking glove pattern
L5 to S2
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

17. several knee pain after being tackled in football game
L5 to S2
Next best step surgery; not ultrasound
When urethral catherization is unsuccessful
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

18. beta hcg and AFP
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elevated non seminomas
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

19. diarrhoea 4-5 days after cholecystectomy
Progressive fibrosis of palmar fascia. etiololgy not known;
Seminomas
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
If any compressive symptoms eg. dysphagia

20. SAH due to posterior inferior cerebellar aneurysm
Dm neuropathy; stocking glove pattern
Headache - ataxia - bulbar dysfunction
Even after ochiopexy risk of ochiopexy higher then general population
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

21. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
If any compressive symptoms eg. dysphagia
Epi and chest compressio for prolong period of time; atropine is given after epi;

22. What is hydrocele?
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Cystic scrotal fluid collection between parietal and visceral layers of testis

23. when scaphoid fx patient needs to be referred to orthopedic
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Fx displace >1mm - nonunion during followup - osteonecrosis
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Sphincter sparing surgery (local resection) - abdomnio perineal resection

24. How to confirm achiles tendon rupture
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Ispilateral hypoglossal nerve injury
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

25. When to do surgery in undesceneded testis?
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Carpal tunnel syndrom

26. antibiotics of acute cholecystitis
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Malignancy until proven otherwise
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Study showed no adverse effect; but they are contraindicated for PVD

27. clavicle fx
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
L5 to S2
Tendons more likely
Displaced ORIF ; nondisplaced sling immobilization

28. perioral numbness after parathyroidectomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
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
ACL injury

29. How to perform lachman test
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Unilateral vocal cord paralysis
50%; tunneling between rectum or kin
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

30. surgery for acute cholecystities
Less than 5mm
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
24-48 hours of supportive therapy followed by cholecystectomy
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

31. contraindication of urethral catheterization
Twisting force with the foot fixed on the ground seen in football and basketball games;
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Urethral stricture; pelvic of urethral trauma
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

32. Most common of sudden death due to steering wheel injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
S2-S4

33. management of hip fracture
If patient ambulatory - surgery and pain control; if not nonop mx
CRPS
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
SAH due to post communicating artery aneurysm;

34. How to differentiate communicative and non-communicative hydrocele
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity

35. what size of ureteral stone for non op mx
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Less than 5mm
50%; tunneling between rectum or kin

36. When goiter needs surgery
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Even after ochiopexy risk of ochiopexy higher then general population
Pure motor stroke; limited neurological dysfunction
If any compressive symptoms eg. dysphagia

37. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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;
Elderly and critically ill patients
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

38. characteristics of ureteral stone?
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Pure motor stroke; limited neurological dysfunction
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;
Study showed no adverse effect; but they are contraindicated for PVD

39. cat/dog bites
Klinefelter syndrome; 50 fold increase;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
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
Amoxicillin-clavulanate

40. MVC - unrestrained driver - chest bruises - peripheral cyanosis - tachycardia and tahypnoea
Cystic scrotal fluid collection between parietal and visceral layers of testis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
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

41. varicose veins with ulcer - bleeding and thrombophlebitits
Carpal tunnel syndrom
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

42. suprapubic catheterization
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;
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Fx displace >1mm - nonunion during followup - osteonecrosis
When urethral catherization is unsuccessful

43. complications of TPN
Next best step surgery; not ultrasound
Fx displace >1mm - nonunion during followup - osteonecrosis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

44. conservative Tx of varicose veins
Compression stocking - weight reduction - leg elevation
Supraglottic edema; low threshold for intubation
Dumping syndrome; small and frequent meals; no simple sugar
Meniscus injury; medial most common; pain/swelling; popping sensation

45. What is the strongest risk factor for male breast cancer
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Klinefelter syndrome; 50 fold increase;
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
24-48 hours of supportive therapy followed by cholecystectomy

46. What is terrible triad
Next best step surgery; not ultrasound
MAT; medial meniscus injury; ACL and Tibial colateral ligament
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

47. Complications of breast impant
Cystic scrotal fluid collection between parietal and visceral layers of testis
Check ET tube placement if correct needle decompresion
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Dm neuropathy; stocking glove pattern

48. common complication of inadequate mx of scaphoid fx
Nonunion and avascular necrosis; fx can block blood supply;
Progressive fibrosis of palmar fascia. etiololgy not known;
L5 to S2
Compression stocking - weight reduction - leg elevation

49. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
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;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Meniscus injury; medial most common; pain/swelling; popping sensation

50. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Brardycardia - HTN - resp depression
Supraglottic edema; low threshold for intubation

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USMLE Step3 Surgery

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