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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. popping sensation; rapid onset of knee effusion. athelet
When urethral catherization is unsuccessful
ACL injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

2. 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
Meniscus injury; medial most common; pain/swelling; popping sensation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Headache - ataxia - bulbar dysfunction

3. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

4. cat/dog bites
Patellar tendon tear; difficulty in extension
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
Amoxicillin-clavulanate

5. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Dumping syndrome; small and frequent meals; no simple sugar
Retrograde ejaculation
Check ET tube placement if correct needle decompresion

6. menisci injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Twisting force with the foot fixed on the ground seen in football and basketball games;
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;
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

7. first line of management of PVD
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;
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
Low anterior resection and radio; add chemo if node positive

8. management of hip fracture
Low anterior resection and radio; add chemo if node positive
Progressive fibrosis of palmar fascia. etiololgy not known;
If patient ambulatory - surgery and pain control; if not nonop mx
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

9. How to perform lachman test
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
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Increased size during the day and valsalva means it is communicated with peritoneal cavity

10. scrotal trauma
Next best step surgery; not ultrasound
Strok and traumatic brain injury
Compression stocking - weight reduction - leg elevation
Ispilateral hypoglossal nerve injury

11. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
When urethral catherization is unsuccessful
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

12. How to differentiate ACL and meniscus injury
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
Less than 5mm
S2-S4
Strok and traumatic brain injury

13. transrectal prostate biopsy
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

14. Complications of breast impant
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

15. What time frame required for bone remodeling
10-12 months
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Brardycardia - HTN - resp depression
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

16. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Next best step surgery; not ultrasound
Dumping syndrome; small and frequent meals; no simple sugar
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

17. swelling and tenderness in anterior part of knee
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Patellar tendon tear; difficulty in extension

18. 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
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
CRPS
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

19. management of gunshot wound
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
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
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
ACL injury

20. How to confirm achiles tendon rupture
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
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
Elevated non seminomas

21. 27 yo with scrotal mass; warm tender testes feel like bag of worms
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Low anterior resection and radio; add chemo if node positive
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
When urethral catherization is unsuccessful

22. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
SAH due to post communicating artery aneurysm;
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
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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

23. What is terrible triad
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Pure motor stroke; limited neurological dysfunction
Brardycardia - HTN - resp depression
ACL injury

24. antibiotics of acute cholecystitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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;
Displaced ORIF ; nondisplaced sling immobilization

25. lacunar stroke
Dm neuropathy; stocking glove pattern
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Pure motor stroke; limited neurological dysfunction

26. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
MAT; medial meniscus injury; ACL and Tibial colateral ligament
SAH due to post communicating artery aneurysm;
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

27. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

28. how hyperventilation lowers ICP
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Brardycardia - HTN - resp depression
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Retrograde ejaculation

29. 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
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
ACL injury
Elevated non seminomas

30. managment of animal bite in hands
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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;
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;
Patellar tendon tear; difficulty in extension

31. How to confirm dx of compartment syndrom
CRPS
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Unilateral vocal cord paralysis

32. SOB - confusion - petechial rash after trauma - fracture
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Retrograde ejaculation
24-48 hours of supportive therapy followed by cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

33. anal sphincter tone
Elderly and critically ill patients
S2-S4
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

34. Tx of proximal non metastatic rectal ca
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Increased size during the day and valsalva means it is communicated with peritoneal cavity
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Low anterior resection and radio; add chemo if node positive

35. varicocele
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;
Urethral stricture; pelvic of urethral trauma
Ampicillin sublactum - pipercillin - ceftriaxone and metro

36. Why varicocele more common in the left side
When urethral catherization is unsuccessful
Nonunion and avascular necrosis; fx can block blood supply;
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

37. dumping syndrome after gastrectomy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Progressive fibrosis of palmar fascia. etiololgy not known;
Compression stocking - weight reduction - leg elevation

38. tx distal rectal ca
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Saline and silicone
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

39. clavicle fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Displaced ORIF ; nondisplaced sling immobilization
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

40. What is prehn sign?
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Meniscus injury; medial most common; pain/swelling; popping sensation
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
MAT; medial meniscus injury; ACL and Tibial colateral ligament

42. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Pure motor stroke; limited neurological dysfunction
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

43. DD of acute scrotal pain
Unilateral vocal cord paralysis
50%; tunneling between rectum or kin
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

44. How to evaluate painless testicular swelling suspicious for cancer
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Saline and silicone
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

45. when patient with severe lung disease have C02 retention
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
Dm neuropathy; stocking glove pattern
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Retrograde ejaculation

46. ipsilateral deviation of tongue upon protrusion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Ispilateral hypoglossal nerve 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;
Pure motor stroke; limited neurological dysfunction

47. How to manage a patient with asystole
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Epi and chest compressio for prolong period of time; atropine is given after epi;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation

48. acalculus cholecystitis
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Elderly and critically ill patients
Seminomas
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

49. How to manage obesity
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

50. Tx of pulmonary contusion
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;
Twisting force with the foot fixed on the ground seen in football and basketball games;
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

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USMLE Step3 Surgery

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