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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. Patient underwent CABG; postoperatively drowsy. most likely cause?
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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
Subphrenic abscess or other abdominal abscesses; order US or CT
Saline and silicone

2. lacunar stroke
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Pure motor stroke; limited neurological dysfunction
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Abd pain and tenderness; bloody diarrhoea or hematochezia

3. Why ruq calcificaion is concerning
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Seminomas
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
If any compressive symptoms eg. dysphagia

4. cremasteric reflex
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
Malignancy until proven otherwise
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Next best step surgery; not ultrasound

5. How to evaluate painless testicular swelling suspicious for cancer
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Dilatation of pampiniform plexus increase temperature inside scroum; cells in seminiferous tubule are very sensitive to temp and atrophies with inc temp
Elderly and critically ill patients
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein

6. Can we use beta blocker for pvd?
Progressive fibrosis of palmar fascia. etiololgy not known;
Elderly and critically ill patients
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
Study showed no adverse effect; but they are contraindicated for PVD

7. Why varicocele more common in the left side
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
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

8. management of nondisplaced scaphoid 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
Elevated non seminomas
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

9. Tx of pulmonary contusion
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Saline and silicone
Klinefelter syndrome; 50 fold increase;

10. suprapubic catheterization
4-6 weeks for noncontact sports and longer time for contact sports
Dumping syndrome; small and frequent meals; no simple sugar
When urethral catherization is unsuccessful
50%; tunneling between rectum or kin

11. midline neck swelling moves with protrusion of tongue
Increased size during the day and valsalva means it is communicated with peritoneal cavity
50%; tunneling between rectum or kin
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.

12. How to dx ACL tear?
SAH due to post communicating artery aneurysm;
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Study showed no adverse effect; but they are contraindicated for PVD

13. How to manage a patient with asystole
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Epi and chest compressio for prolong period of time; atropine is given after epi;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Flail chest; double rib fractures in more than one site; 10-20% of trauma admissions; increased work of breathing due to muscular spasms;

14. how hyperventilation lowers ICP
Ispilateral hypoglossal nerve injury
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Retrograde ejaculation
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

15. contraindication of urethral catheterization
Epi and chest compressio for prolong period of time; atropine is given after epi;
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Urethral stricture; pelvic of urethral trauma
Less than 5mm

16. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Elevated non seminomas
Fx displace >1mm - nonunion during followup - osteonecrosis
Amoxicillin-clavulanate

17. management of gunshot wound
Dm neuropathy; stocking glove pattern
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
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Brardycardia - HTN - resp depression

18. SAH due to posterior inferior cerebellar aneurysm
Retrograde ejaculation
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Headache - ataxia - bulbar dysfunction
Even after ochiopexy risk of ochiopexy higher then general population

19. inhalation of hot air - steam - smoke in burn victim
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Supraglottic edema; low threshold for intubation

20. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Subphrenic abscess or other abdominal abscesses; order US or CT
24-48 hours of supportive therapy followed by cholecystectomy
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

21. Tx of proximal non metastatic rectal ca
Low anterior resection and radio; add chemo if node positive
L5 to S2
24-48 hours of supportive therapy followed by cholecystectomy
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

22. how ABI help dx of PVD
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
S2-S4
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

23. dorsiflexion and planter flexion
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Abd pain and tenderness; bloody diarrhoea or hematochezia
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
L5 to S2

24. transrectal prostate biopsy
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Brardycardia - HTN - resp depression

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

26. How to differentiate communicative and non-communicative hydrocele
Pure motor stroke; limited neurological dysfunction
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

27. severe abd pain; ct scan neg and cardiac history; metabolic acidosis
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
If any compressive symptoms eg. dysphagia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
ABI below 0.9 suggest pvd; below 0.4 severe ischemia

28. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
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
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
SAH due to post communicating artery aneurysm;

29. What is prehn sign?
Pure motor stroke; limited neurological dysfunction
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis
Malignancy until proven otherwise
If patient ambulatory - surgery and pain control; if not nonop mx

30. How mcmurray manuver perform
Strok and traumatic brain 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
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal 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;

31. How to confirm achiles tendon rupture
L5 to S2
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

32. conservative Tx of varicose veins
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Compression stocking - weight reduction - leg elevation
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA

33. popping sensation; rapid onset of knee effusion. athelet
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
ACL injury
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
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

34. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Study showed no adverse effect; but they are contraindicated for PVD
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

35. what size of ureteral stone for non op mx
Supraglottic edema; low threshold for intubation
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Less than 5mm
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

36. first step for evaluation of testicular swelling
If patient ambulatory - surgery and pain control; if not nonop mx
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

37. SOB - confusion - petechial rash after trauma - fracture
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Study showed no adverse effect; but they are contraindicated for PVD
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

38. antibiotics of acute cholecystitis
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Ampicillin sublactum - pipercillin - ceftriaxone and metro

39. several knee pain after being tackled in football game
Mammogram
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Brardycardia - HTN - resp depression

40. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Malignancy until proven otherwise
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
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

41. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Check ET tube placement if correct needle decompresion
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

42. clavicle fx
Displaced ORIF ; nondisplaced sling immobilization
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Cilostazol; phosphodiesterase inhibitor; inhibits platelet aggregation and arterial vasodilator; improve maximal walking distance;
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

43. 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
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
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

44. managment of animal bite in hands
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;
ACL injury
Ampicillin sublactum - pipercillin - ceftriaxone and metro
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

45. common complication of inadequate mx of scaphoid fx
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Sphincter sparing surgery (local resection) - abdomnio perineal resection
Nonunion and avascular necrosis; fx can block blood supply;

46. suddent turning while running; twisting injury to the knee with one foot fixed to the ground
Meniscus injury; medial most common; pain/swelling; popping sensation
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Dumping syndrome; small and frequent meals; no simple sugar
Supraglottic edema; low threshold for intubation

47. Why right varicocele is more concerning?

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48. mx of stress fx
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram

49. most common complication of acute cholecystitis
Abd pain and tenderness; bloody diarrhoea or hematochezia
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Tendons more likely
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;

50. scrotal trauma
Klinefelter syndrome; 50 fold increase;
Next best step surgery; not ultrasound
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Displaced ORIF ; nondisplaced sling immobilization