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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. When goiter needs surgery
Mammogram
Check ET tube placement if correct needle decompresion
Nonunion and avascular necrosis; fx can block blood supply;
If any compressive symptoms eg. dysphagia

2. management of nondisplaced scaphoid fx
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
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
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Amoxicillin-clavulanate

3. how ABI help dx of PVD
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Fx displace >1mm - nonunion during followup - osteonecrosis

4. What is most common lung injury after blunt chest trauma?
Even after ochiopexy risk of ochiopexy higher then general population
If patient ambulatory - surgery and pain control; if not nonop mx
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
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

5. How to manage a patient with asystole
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
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
Brardycardia - HTN - resp depression

6. inhalation of hot air - steam - smoke in burn victim
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
ACL injury
Supraglottic edema; low threshold for intubation
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

7. swelling and tenderness in anterior part of knee
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Low anterior resection and radio; add chemo if node positive
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Patellar tendon tear; difficulty in extension

8. mx of stress 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
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Epi and chest compressio for prolong period of time; atropine is given after epi;
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx

9. pregnant patient with asymptomatic gall stones
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Less than 5mm
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

10. When to stop raloxifene before surgery
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Klinefelter syndrome; 50 fold increase;
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

11. most frequent complication of TURP
If gall stones are asymptomatic - no tx; symptomatic patient- lap chole
Retrograde ejaculation
Elderly and critically ill patients
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

12. midline neck swelling moves with protrusion of tongue
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
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
Nonunion and avascular necrosis; fx can block blood supply;

13. management of gunshot wound
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Study showed no adverse effect; but they are contraindicated for PVD
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

14. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
Retrograde ejaculation
Check ET tube placement if correct needle decompresion
Even after ochiopexy risk of ochiopexy higher then general population
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;

15. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
Saline and silicone
Next best step surgery; not ultrasound
Subphrenic abscess or other abdominal abscesses; order US or CT

16. menisci injury
Twisting force with the foot fixed on the ground seen in football and basketball games;
Displaced ORIF ; nondisplaced sling immobilization
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
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg

17. 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
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Headache - ataxia - bulbar dysfunction
15-40%; self limiting;doesn't require tx

18. characteristics of ureteral stone?
SAH due to post communicating artery aneurysm;
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

19. How to confirm dx of compartment syndrom
Urethral stricture; pelvic of urethral trauma
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
Elderly and critically ill patients
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy

20. sudden onset of severe periumbilical pain/n/v; AF; hx of MI
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Amoxicillin-clavulanate
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal
Retrograde ejaculation

21. sudden onset of postoperative hyperglycemia when patient on TPN
24-48 hours of supportive therapy followed by cholecystectomy
Low anterior resection and radio; add chemo if node positive
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Next best step surgery; not ultrasound

22. beta HCG
15-40%; self limiting;doesn't require tx
Tendons more likely
Elderly and critically ill patients
Seminomas

23. Valgus and Varus tests
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Epi and chest compressio for prolong period of time; atropine is given after epi;
Progressive fibrosis of palmar fascia. etiololgy not known;

24. How to confirm achiles tendon rupture
Pure motor stroke; limited neurological dysfunction
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
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

25. What is the contraindication of hyperventilation in inc ICP
Check tissue pressure; above 30 mm Hg is diagnostic; tx emergent fasciotomy
Saline and silicone
Strok and traumatic brain injury
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

26. indication of ursodeoxycholic acid
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
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
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position

27. lacerated wound in palmer surface of hand. what structure is injured?
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Tendons more likely
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
Low anterior resection and radio; add chemo if node positive

28. varicose veins with ulcer - bleeding and thrombophlebitits
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Low anterior resection and radio; add chemo if node positive
50%; tunneling between rectum or kin
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins

29. How mcmurray manuver perform
Tendons more likely
Knee full flexed then externally rotated and extended slowly; audible click is positive for meniscal injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line

30. differential of ultrasound finding of breast mass
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
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
4-6 weeks for noncontact sports and longer time for contact sports
Scrotal ultrasound; cystic and fluid filled collections are noncancerous

31. What is the strongest risk factor for male breast cancer
Klinefelter syndrome; 50 fold increase;
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
Dumping syndrome; small and frequent meals; no simple sugar
Nonunion and avascular necrosis; fx can block blood supply;

32. What time frame required for bone remodeling
10-12 months
If any compressive symptoms eg. dysphagia
Amoxicillin-clavulanate
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

33. Dupuytren contracture
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
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Progressive fibrosis of palmar fascia. etiololgy not known;
Mesenteric ischemia; emboli form due to AF turbulence can occlude mesenteri artery causing mesenteric ischemia; abd exam normal

34. What is cushing's triad
Progressive fibrosis of palmar fascia. etiololgy not known;
Brardycardia - HTN - resp depression
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;
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

35. types of hip fracture
Tendons more likely
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur
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;

36. Why right varicocele is more concerning?

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37. Most common of sudden death due to steering wheel injury
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
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;
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

38. Complications of breast impant
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
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

39. What is hydrocele?
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Cystic scrotal fluid collection between parietal and visceral layers of testis
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

40. Why initial xrays are negative in scaphoid fx
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Cystic scrotal fluid collection between parietal and visceral layers of testis
Less than 5mm
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

41. sudden onset of headache; right sided ptosis - anisocoria - nuchal rigidity
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
Increased size during the day and valsalva means it is communicated with peritoneal cavity
SAH due to post communicating artery aneurysm;

42. beta hcg and AFP
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Elevated non seminomas
Displaced ORIF ; nondisplaced sling immobilization
Strok and traumatic brain injury

43. 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.
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
Epi and chest compressio for prolong period of time; atropine is given after epi;
ACL injury

44. recurrent laryngeal nerve injury
Elderly and critically ill patients
S2-S4
Epi and chest compressio for prolong period of time; atropine is given after epi;
Unilateral vocal cord paralysis

45. dorsiflexion and planter flexion
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Check ET tube placement if correct needle decompresion
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;
L5 to S2

46. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
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
Pain relief with testis elevation; not reliable absent in testicular torsion and present in epidymitis

47. acute colonic ischemia
If any compressive symptoms eg. dysphagia
24-48 hours of supportive therapy followed by cholecystectomy
Abd pain and tenderness; bloody diarrhoea or hematochezia
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

48. How to differentiate ACL and meniscus injury
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
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
Elevated non seminomas
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;

49. What percent of anal abscess deveolop fisutula
Displaced ORIF ; nondisplaced sling immobilization
50%; tunneling between rectum or kin
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;
Elderly and critically ill patients

50. How to differentiate communicative and non-communicative hydrocele
10-12 months
Increased size during the day and valsalva means it is communicated with peritoneal cavity
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
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile

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USMLE Step3 Surgery

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