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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. What is cushing's triad
Brardycardia - HTN - resp depression
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Headache - ataxia - bulbar dysfunction
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case

2. suprapubic catheterization
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)
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

3. mangement of localized lymphadenopathy
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Amoxicillin-clavulanate
15-40%; self limiting;doesn't require tx
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

4. management of nondisplaced scaphoid fx
Twisting force with the foot fixed on the ground seen in football and basketball games;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
<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

5. menisci injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
If any compressive symptoms eg. dysphagia
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Twisting force with the foot fixed on the ground seen in football and basketball games;

6. beta HCG
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Seminomas

7. Why ruq calcificaion is concerning
Subphrenic abscess or other abdominal abscesses; order US or CT
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Progressive fibrosis of palmar fascia. etiololgy not known;

8. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Seminomas
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
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

9. How to evaluate painless testicular swelling suspicious for cancer
10-12 months
Progressive fibrosis of palmar fascia. etiololgy not known;
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
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

10. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
10-12 months
Compression stocking - weight reduction - leg elevation
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

11. conservative Tx of varicose veins
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;
Headache - ataxia - bulbar dysfunction
ACL injury
Compression stocking - weight reduction - leg elevation

12. How to confirm achiles tendon rupture
Elderly and critically ill patients
Strok and traumatic brain 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
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

13. varicose veins with ulcer - bleeding and thrombophlebitits
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
15-40%; self limiting;doesn't require tx
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

14. Incidence of AF in CABG patient

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15. recurrent laryngeal nerve injury
Strok and traumatic brain injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Unilateral vocal cord paralysis
Ispilateral hypoglossal nerve injury

16. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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

17. management of stone 8-10mm
L5 to S2
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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

18. painless testicular mass in young male
Nonunion and avascular necrosis; fx can block blood supply;
4-6 weeks for noncontact sports and longer time for contact sports
Malignancy until proven otherwise
Amoxicillin-clavulanate

19. When to do surgery in undesceneded testis?
Elevated non seminomas
Dumping syndrome; small and frequent meals; no simple sugar
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

20. Why varicocele more common in the left side
Tendons more likely
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
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

21. How mcmurray manuver perform
Next best step surgery; not ultrasound
S2-S4
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury

22. types of hip fracture
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
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
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
If any compressive symptoms eg. dysphagia

23. dorsiflexion and planter flexion
L5 to S2
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;
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea

24. What is the strongest risk factor for male breast cancer
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Klinefelter syndrome; 50 fold increase;
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

25. Tx of proximal non metastatic rectal ca
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Low anterior resection and radio; add chemo if node positive
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole

26. mx of stress fx
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
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
Pure motor stroke; limited neurological dysfunction
4-6 weeks for noncontact sports and longer time for contact sports

27. 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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Displaced ORIF ; nondisplaced sling immobilization
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele

28. What types of breast implants are available
Saline and silicone
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If patient ambulatory - surgery and pain control; if not nonop mx
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

29. how hyperventilation lowers ICP
Retrograde ejaculation
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Saline and silicone
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

30. most common fx when falling on outsretched hand
Malignancy until proven otherwise
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
10-12 months
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

31. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
CRPS
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Abd pain and tenderness; bloody diarrhoea or hematochezia
Fx displace >1mm - nonunion during followup - osteonecrosis

32. aspiration of breast cyst is bloody
Mammogram
Meniscus injury; medial most common; pain/swelling; popping sensation
Malignancy until proven otherwise
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism

33. ipsilateral deviation of tongue upon protrusion
Ispilateral hypoglossal nerve injury
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

34. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Less than 5mm
When urethral catherization is unsuccessful
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Check ET tube placement if correct needle decompresion

35. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
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
Tendons more likely
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

36. Tx of pulmonary contusion
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
Seminomas
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;

37. ct scan; cystic lesion in head of pancreas; next step
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
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

38. MVC - unresponsive - bleeding from head - decr RR - unilat pupilary dilation - seizure
4-6 weeks for noncontact sports and longer time for contact sports
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

39. most common complication of acute cholecystitis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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
Strok and traumatic brain injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

40. Why initial xrays are negative in scaphoid fx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Low anterior resection and radio; add chemo if node positive
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
Klinefelter syndrome; 50 fold increase;

41. How to differentiate ACL and meniscus injury
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
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
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
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

42. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
SAH due to post communicating artery aneurysm;
Meniscus injury; medial most common; pain/swelling; popping sensation
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

43. Most common of sudden death due to steering wheel injury
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
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
L5 to S2
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele

44. Dupuytren contracture
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;
Progressive fibrosis of palmar fascia. etiololgy not known;
Nonunion and avascular necrosis; fx can block blood supply;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

45. management of gunshot wound
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;
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
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

46. first step for evaluation of testicular swelling
SAH due to post communicating artery aneurysm;
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Progressive fibrosis of palmar fascia. etiololgy not known;
Supraglottic edema; low threshold for intubation

47. inhalation of hot air - steam - smoke in burn victim
Supraglottic edema; low threshold for intubation
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa

48. When goiter needs surgery
Ispilateral hypoglossal nerve injury
If any compressive symptoms eg. dysphagia
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;
MAT; medial meniscus injury; ACL and Tibial colateral ligament

49. 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;
Ispilateral hypoglossal nerve injury
L5 to S2

50. swelling and tenderness in anterior part of knee
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
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Patellar tendon tear; difficulty in extension
Fx displace >1mm - nonunion during followup - osteonecrosis

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USMLE Step3 Surgery

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