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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. How to differentiate communicative and non-communicative hydrocele
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Dm neuropathy; stocking glove pattern

2. differential of ultrasound finding of breast mass
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
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
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
If patient ambulatory - surgery and pain control; if not nonop mx

3. lacerated wound in palmer surface of hand. what structure is injured?
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Tendons more likely
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

4. How to dx ACL tear?
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
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
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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

5. What is the complications of undescended testis
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Even after ochiopexy risk of ochiopexy higher then general population
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

6. Why initial xrays are negative in scaphoid fx
Mammogram
Check ET tube placement if correct needle decompresion
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

7. midline neck swelling moves with protrusion of tongue
Study showed no adverse effect; but they are contraindicated for PVD
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
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery

8. beta HCG
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Seminomas

9. most common fx when falling on outsretched hand
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Fx displace >1mm - nonunion during followup - osteonecrosis
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

10. Most common of sudden death due to steering wheel injury
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Dm neuropathy; stocking glove pattern

11. most frequent complication of TURP
Study showed no adverse effect; but they are contraindicated for PVD
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
10-12 months
Retrograde ejaculation

12. mangement of localized lymphadenopathy
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Urethral stricture; pelvic of urethral trauma
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
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

13. What time frame required for bone remodeling
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
10-12 months

14. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Saline and silicone
Study showed no adverse effect; but they are contraindicated for PVD
MAT; medial meniscus injury; ACL and Tibial colateral ligament

15. when scaphoid fx patient needs to be referred to orthopedic
Less than 5mm
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Malignancy until proven otherwise
Fx displace >1mm - nonunion during followup - osteonecrosis

16. ipsilateral deviation of tongue upon protrusion
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Ispilateral hypoglossal nerve injury
Subphrenic abscess or other abdominal abscesses; order US or CT
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp

17. complication displaced or communited distal radial fx
Patellar tendon tear; difficulty in extension
Urethral stricture; pelvic of urethral trauma
Carpal tunnel syndrom
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

18. characteristics of ureteral stone?
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Compression stocking - weight reduction - leg elevation

19. What is terrible triad
Unilateral vocal cord paralysis
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
If any compressive symptoms eg. dysphagia
MAT; medial meniscus injury; ACL and Tibial colateral ligament

20. 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
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Retrograde ejaculation
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

21. Valgus and Varus tests
Headache - ataxia - bulbar dysfunction
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Even after ochiopexy risk of ochiopexy higher then general population

22. pregnant patient with asymptomatic gall stones
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Abd pain and tenderness; bloody diarrhoea or hematochezia
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

23. tx distal rectal ca
15-40%; self limiting;doesn't require tx
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sphincter sparing surgery (local resection) - abdomnio perineal resection
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

24. 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.
Fx displace >1mm - nonunion during followup - osteonecrosis
Elderly and critically ill patients
Tendons more likely

25. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

26. clavicle fx
Strok and traumatic brain injury
Displaced ORIF ; nondisplaced sling immobilization
Progressive fibrosis of palmar fascia. etiololgy not known;
Compression stocking - weight reduction - leg elevation

27. How to perform lachman test
ACL injury
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal

28. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
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
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
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

29. Why varicocele more common in the left side
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum

30. scrotal trauma
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Next best step surgery; not ultrasound
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal

31. When to do surgery in undesceneded testis?
S2-S4
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
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
SAH due to post communicating artery aneurysm;

32. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
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

33. popping sensation; rapid onset of knee effusion. athelet
Next best step surgery; not ultrasound
ACL injury
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Sphincter sparing surgery (local resection) - abdomnio perineal resection

34. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Mammogram
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
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

35. contraindication of urethral catheterization
Urethral stricture; pelvic of urethral trauma
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abd pain and tenderness; bloody diarrhoea or hematochezia
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;

36. first line of management of PVD
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Subphrenic abscess or other abdominal abscesses; order US or CT
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

37. 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
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Amoxicillin-clavulanate

38. acute colonic ischemia
Abd pain and tenderness; bloody diarrhoea or hematochezia
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
50%; tunneling between rectum or kin

39. When patient can go back to sports after clavicle fx
Unilateral vocal cord paralysis
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Dumping syndrome; small and frequent meals; no simple sugar
4-6 weeks for noncontact sports and longer time for contact sports

40. lacunar stroke
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Headache - ataxia - bulbar dysfunction
Pure motor stroke; limited neurological dysfunction
10-12 months

41. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
24-48 hours of supportive therapy followed by cholecystectomy
10-12 months
Meniscus injury; medial most common; pain/swelling; popping sensation
Low anterior resection and radio; add chemo if node positive

42. Dupuytren contracture
Progressive fibrosis of palmar fascia. etiololgy not known;
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Headache - ataxia - bulbar dysfunction
Next best step surgery; not ultrasound

43. What is the strongest risk factor for male breast cancer
4-6 weeks for noncontact sports and longer time for contact sports
ACL 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
Klinefelter syndrome; 50 fold increase;

44. complication of distal radial fx and wrist fx splinted with palmar flexion at 15
50%; tunneling between rectum or kin
CRPS
Urethral stricture; pelvic of urethral trauma
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion

45. management of nondisplaced scaphoid fx
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
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
Patellar tendon tear; difficulty in extension

46. conservative Tx of varicose veins
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Klinefelter syndrome; 50 fold increase;
Compression stocking - weight reduction - leg elevation
SAH due to post communicating artery aneurysm;

47. stress fx
Compression stocking - weight reduction - leg elevation
Retrograde ejaculation
Even after ochiopexy risk of ochiopexy higher then general population
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

48. aspiration of breast cyst is bloody
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Mammogram
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

49. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;

50. What is prehn sign?
Fx displace >1mm - nonunion during followup - osteonecrosis
Compression stocking - weight reduction - leg elevation
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare

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USMLE Step3 Surgery

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