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USMLE Step3 Surgery

Subjects : health-sciences, usmle-step-3

Instructions:

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. 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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Tendons more likely
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

2. first line of management of PVD
Abd pain and tenderness; bloody diarrhoea or hematochezia
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Ispilateral hypoglossal nerve injury

3. indication of ursodeoxycholic acid
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
Nonunion and avascular necrosis; fx can block blood supply;
Amoxicillin-clavulanate
Elderly and critically ill patients

4. beta hcg and AFP
Elevated non seminomas
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
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

5. swelling and tenderness in anterior part of knee
Progressive fibrosis of palmar fascia. etiololgy not known;
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
15-40%; self limiting;doesn't require tx
Patellar tendon tear; difficulty in extension

6. What is the strongest risk factor for male breast cancer
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
Less than 5mm
15-40%; self limiting;doesn't require tx

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

8. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Check ET tube placement if correct needle decompresion
Amoxicillin-clavulanate
Retrograde ejaculation
Malignancy until proven otherwise

9. management of nondisplaced scaphoid fx
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
Retrograde ejaculation
Meniscus injury; medial most common; pain/swelling; popping sensation

10. cremasteric reflex test?
Dumping syndrome; small and frequent meals; no simple sugar
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Patellar tendon tear; difficulty in extension
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

11. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Amoxicillin-clavulanate
Subphrenic abscess or other abdominal abscesses; order US or CT
Study showed no adverse effect; but they are contraindicated for PVD

12. What is hydrocele?
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Urethral stricture; pelvic of urethral trauma
Pure motor stroke; limited neurological dysfunction
Cystic scrotal fluid collection between parietal and visceral layers of testis

13. scrotal trauma
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Next best step surgery; not ultrasound
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
L5 to S2

14. 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
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
When urethral catherization is unsuccessful

15. suprapubic catheterization
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
When urethral catherization is unsuccessful
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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

16. Tx of proximal non metastatic rectal ca
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Low anterior resection and radio; add chemo if node positive

17. mangement of localized lymphadenopathy
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

18. aspiration of breast cyst is bloody
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
24-48 hours of supportive therapy followed by cholecystectomy
Mammogram
Compression stocking - weight reduction - leg elevation

19. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Strok and traumatic brain injury
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Subphrenic abscess or other abdominal abscesses; order US or CT
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

20. When to do surgery in undesceneded testis?
Low anterior resection and radio; add chemo if node positive
4-6 weeks for noncontact sports and longer time for contact sports
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Amoxicillin-clavulanate

21. Most common of sudden death due to steering wheel 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
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;
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

22. SAH due to posterior inferior cerebellar aneurysm
Headache - ataxia - bulbar dysfunction
Supraglottic edema; low threshold for intubation
Fx displace >1mm - nonunion during followup - osteonecrosis
Pure motor stroke; limited neurological dysfunction

23. painless testicular mass in young male
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Malignancy until proven otherwise
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
S2-S4

24. When to stop raloxifene before surgery
CRPS
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Sphincter sparing surgery (local resection) - abdomnio perineal resection

25. xray finding of stress fx after 3-4w
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Seminomas
S2-S4
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

26. How to manage a patient with asystole
L5 to S2
Study showed no adverse effect; but they are contraindicated for PVD
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Epi and chest compressio for prolong period of time; atropine is given after epi;

27. complication displaced or communited distal radial fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
10-12 months
SAH due to post communicating artery aneurysm;
Carpal tunnel syndrom

28. recurrent laryngeal nerve injury
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
10-12 months
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
Unilateral vocal cord paralysis

29. common complication of inadequate mx of scaphoid fx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
Nonunion and avascular necrosis; fx can block blood supply;
L5 to S2
Malignancy until proven otherwise

30. What types of breast implants are available
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
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
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Saline and silicone

31. lacerated wound in palmer surface of hand. what structure is injured?
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Next best step surgery; not ultrasound
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Tendons more likely

32. inhalation of hot air - steam - smoke in burn victim
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
15-40%; self limiting;doesn't require tx
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
Supraglottic edema; low threshold for intubation

33. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

34. Complications of breast impant
Mammogram
Cystic scrotal fluid collection between parietal and visceral layers of testis
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;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

35. What is cushing's triad
Brardycardia - HTN - resp depression
4-6 weeks for noncontact sports and longer time for contact sports
Dm neuropathy; stocking glove pattern
Fx displace >1mm - nonunion during followup - osteonecrosis

36. tx distal rectal ca
24-48 hours of supportive therapy followed by cholecystectomy
If any compressive symptoms eg. dysphagia
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sphincter sparing surgery (local resection) - abdomnio perineal resection

37. 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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If any compressive symptoms eg. dysphagia

38. When patient can go back to sports after clavicle fx
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;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
4-6 weeks for noncontact sports and longer time for contact sports

39. several knee pain after being tackled in football game
Patellar tendon tear; difficulty in extension
CRPS
Headache - ataxia - bulbar dysfunction
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

40. What are the common injuries from lightning?
24-48 hours of supportive therapy followed by cholecystectomy
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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

41. Why varicocele more common in the left side
Dm neuropathy; stocking glove pattern
S2-S4
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Even after ochiopexy risk of ochiopexy higher then general population

42. management of stone 8-10mm
Study showed no adverse effect; but they are contraindicated for PVD
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

43. perioral numbness after parathyroidectomy
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
Patellar tendon tear; difficulty in extension
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
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;

44. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

45. How to dx ACL tear?
15-40%; self limiting;doesn't require tx
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
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

46. prostate enlarged - nontender - no nodularity - elevated PSA
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

47. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Saline and silicone

48. How to differentiate ACL and meniscus injury
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
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
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
Supraglottic edema; low threshold for intubation

49. contraindication of urethral catheterization
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Carpal tunnel syndrom
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Urethral stricture; pelvic of urethral trauma

50. Tx of pulmonary contusion
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elderly and critically ill patients
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Retrograde ejaculation

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USMLE Step3 Surgery

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