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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 time frame required for bone remodeling
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
10-12 months
Follow up 3-4 weeks for complete resolution; if not resolved do lymph node bx
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol

2. acalculus cholecystitis
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
If any compressive symptoms eg. dysphagia
Elderly and critically ill patients

3. What types of breast implants are available
Study showed no adverse effect; but they are contraindicated for PVD
Ispilateral hypoglossal nerve injury
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Saline and silicone

4. stress fx
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Malignancy until proven otherwise
If there is any residual mass present mammogram; if not f/you in 4-6 weeks; if mass came back mammogram
TTP and local swelling; plain xray mostly negative withn 2-3 weeks of symptom onset

5. laparotomy 2 weeks ago - now pain in right shoulder tip; fever and tachycardia
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Subphrenic abscess or other abdominal abscesses; order US or CT
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

6. What is most common lung injury after blunt chest trauma?
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
Unilateral vocal cord paralysis
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration

7. midline neck swelling moves with protrusion of tongue
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Supraglottic edema; low threshold for intubation
When urethral catherization is unsuccessful
L5 to S2

8. how ABI help dx of PVD
ABI below 0.9 suggest pvd; below 0.4 severe ischemia
Infection most common; atrophy of bowel mucosa--disruption of normal mucosal barrier allow intestinal bacteria to enter systemic circulation
If any compressive symptoms eg. dysphagia
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
SAH due to post communicating artery aneurysm;
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
10-12 months

10. Why initial xrays are negative in scaphoid fx
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
Fx displace >1mm - nonunion during followup - osteonecrosis
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches

11. SOB - confusion - petechial rash after trauma - fracture
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
<10mm and proximal: ESWL (extracorporeal shockwave lithotripsy) and >10 mm proximal and all distal: flexible ureterscopy and laser lithotripsy; dial

12. transrectal prostate biopsy
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Ampicillin sublactum - pipercillin - ceftriaxone and metro

13. suprapubic catheterization
When urethral catherization is unsuccessful
Patellar tendon tear; difficulty in extension
CRPS
Epi and chest compressio for prolong period of time; atropine is given after epi;

14. cremasteric reflex
Study showed no adverse effect; but they are contraindicated for PVD
Dm neuropathy; stocking glove pattern
Absent in L1 to L2 lesion; associated with decreased hip flexion and adduction
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;

15. 27 yo with scrotal mass; warm tender testes feel like bag of worms
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
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus

16. How to differentiate communicative and non-communicative hydrocele
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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

17. first step for evaluation of testicular swelling
Scrotal ultrasound; cystic and fluid filled collections are noncancerous
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
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
Retrograde ejaculation

18. beta HCG
Urethral stricture; pelvic of urethral trauma
Intracapsular involves femoral head and neck and extracapsular involves intertrochanteric and subtrochanteric; complication-avascular necrosis;
Seminomas
Epi and chest compressio for prolong period of time; atropine is given after epi;

19. conservative Tx of varicose veins
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
Compression stocking - weight reduction - leg elevation
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Next best step surgery; not ultrasound

20. What is the complications of undescended testis
Urethral stricture; pelvic of urethral trauma
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
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
Even after ochiopexy risk of ochiopexy higher then general population

21. What is hydrocele?
Cystic scrotal fluid collection between parietal and visceral layers of testis
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Mammogram
Brardycardia - HTN - resp depression

22. How to manage obesity
Calorie restriction - exercise - behavioral modification; if fails orlistat - if fails bariatric surg
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Subphrenic abscess or other abdominal abscesses; order US or CT
50%; tunneling between rectum or kin

23. What is terrible triad
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
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
MAT; medial meniscus injury; ACL and Tibial colateral ligament
Indirect inguinal hernia most likely failure to obliteration of processus vaginalis; tx surgical repair asap to avoid risk of incarceration - no wait;

24. popping sensation; rapid onset of knee effusion. athelet
Abd pain and tenderness; bloody diarrhoea or hematochezia
Short arm thumb spica cast; f/you xray every 2weeks to monitor healing; rigid wrist protection for 2m after cast removal
Ampicillin sublactum - pipercillin - ceftriaxone and metro
ACL injury

25. Indication for bariatric surgery in obese patients
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
Varicocele; due to failure of obliteration of processus vaginalis; tx surgey asap to avoid incarceration
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;
Study showed no adverse effect; but they are contraindicated for PVD

26. most common complication of acute cholecystitis
4 weeks before; increases risk of in thromembolism in perioperative period when patient is immobile
Gall bladder gangrene and perforation; cholecystoenteric fistula; emphysematous cholecystitis;
Ampicillin sublactum - pipercillin - ceftriaxone and metro
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

27. swelling and tenderness in anterior part of knee
Study showed no adverse effect; but they are contraindicated for PVD
Patellar tendon tear; difficulty in extension
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
Carpal tunnel syndrom

28. Complications of breast impant
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;
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA

29. prostate enlarged - nontender - no nodularity - elevated PSA
Compression stocking - weight reduction - leg elevation
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
If patient ambulatory - surgery and pain control; if not nonop mx
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

30. contraindication of urethral catheterization
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
If prostate nodular - indurated and asymmetrical in digital rectal exam; with or without increased PSA
Urethral stricture; pelvic of urethral trauma

31. most common fx when falling on outsretched hand
Ampicillin sublactum - pipercillin - ceftriaxone and metro
Ispilateral hypoglossal nerve injury
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu
Scaphoid fx; p/w dec ROM - radial wrist pain and swelling; TTP anatomical snuffbox; if xray neg - do MRI

32. How to evaluate painless testicular swelling suspicious for cancer
Severe pain; torsion or epididymis; if associated with swelling; hydrocele - varicocele - spermatocele
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Even after ochiopexy risk of ochiopexy higher then general population

33. painless testicular mass in young male
It lowers PCO2 to 25-30 mm hg and constricts cerebral vessels;
Compression stocking - weight reduction - leg elevation
Elevation of testis in response to stroking of upper thigh; absent in boys under 6m and testicular torsion
Malignancy until proven otherwise

34. recurrent laryngeal nerve injury
Thyroglossal cyst; ectopic thryroid tissue may present - imaging CT/nuclear scan/US mandatory before surgery
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Unilateral vocal cord paralysis
Elevated non seminomas

35. How to perform lachman test
Complete cessation of all physical activity for 4-6 weeks and gradual return to activity; NSAID and crutches
Sepsis; look for the source of infetion; line sepsis - pneumonia - wound infection;
Aortic rupture; most common site -ligamentum arteriosum - aortic root and diaphragmatic hiatus
Knee flexed at 20 degree; one hand pulls proximal tibia and other hand stabilizes femur

36. surgery for acute cholecystities
24-48 hours of supportive therapy followed by cholecystectomy
Compression stocking - weight reduction - leg elevation
Increased ICP; initially headcha - vomiting - blurry vision - papilledema; then AMS - ipsilateral pupil dilation - nerve palsy and hemiparesis; tx ABC intubate then mannitol
Less than 5mm

37. desatig plus decreasesd breath sound in one side of chest in patient with ET tube
It could be porcelin GB which has high risk of devleoping Ca; Tx CT then elective cholecystectomy
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Seminomas
Check ET tube placement if correct needle decompresion

38. diarrhoea 4-5 days after cholecystectomy
Dumping syndrome; small and frequent meals; no simple sugar
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
EUS and aspiration; most effective for biopsying LN - lesion in pancreas - liver - adrenal gland - bile duct - peritoneal and pleural fluid.
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid

39. What is cushing's triad
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Sudden cardiac arrest (asystole) - rhadomyolysis - autonomic dysfunction causing fixed dilated pupil; local burn - ruptured eardrum
Increased size during the day and valsalva means it is communicated with peritoneal cavity
Brardycardia - HTN - resp depression

40. When to do surgery in undesceneded testis?
Within 6 moths and definitely before 1 yrs; after 6 months - chances of spontaneous descent is rare
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
5-10% patient; increased bile acid flux caused diarrhea; tx cholestyramine which sequester excess bile acid
Increased size during the day and valsalva means it is communicated with peritoneal cavity

41. characteristics of ureteral stone?
Abdomen CT to evaluate lymph node metastasis; serum marker beta HCG and alpha feto protein
Carpal tunnel syndrom
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;
Colicky; waxing and waning; upper ureteral stone-pain in flank; lower ureteral stone pain radiates to ipsilateral groin area

42. 3 weeks after trauma - intense pain - swelling - dec ROM - skin changes
Capsular contracture resulting pain - distortion of shape - implant deflation - rupture; tx implant removal
CRPS; type 1 no nerve lesion - 90% of cases; type 2 with nerve lesion; tx nerve block or intravensou regional anesthesa
10-12 months
Supraglottic edema; low threshold for intubation

43. young patient with s/s mitral valve obstruction - now p/w diminished unitlateral pulses - foot pain and cold extremity
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
Dm neuropathy; stocking glove pattern
Acute mesenteric ishemia; most SMA occlusion secondary to an embolism
Atrial myxoma; look for suden onset of symptoms which most likely an embolus; myxoma frequently embolize to systemic circu

44. Why varicocele more common in the left side
It drains to left renal vein at a right angle; any renal mass/disease obstruct venous flow and casues varicocele
Pumonary toileting - pain control - restrict fluid to control edema - oxygen; intubation required in severe case
Subphrenic abscess or other abdominal abscesses; order US or CT
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)

45. dumping syndrome after gastrectomy
Cortical thickening - periosteal elevation - bone sclerosis - true fracture line
Rapid passage of liquid and food into jejunum faster; leads to diarrhoea - nausea - vomiting - dizziness - sweating - dyspnoea
Displaced ORIF ; nondisplaced sling immobilization
Sphincter sparing surgery (local resection) - abdomnio perineal resection

46. Valgus and Varus tests
Tendons more likely
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
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;
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line

47. differential of ultrasound finding of breast mass
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
If large surgical ligation and stipping. if small - try conservation tx if fails after 3-6m - inject sclerosing agent into veins
Urethral stricture; pelvic of urethral trauma
Fat embolism; they develop petechia coz dermal capillaries are occluded by fat particles

48. How to dx ACL tear?
Rechechek PSA in 2-4 weeks; BPH can have elevated PSA
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
Twisting force with the foot fixed on the ground seen in football and basketball games;
Patellar tendon tear; difficulty in extension

49. severe pain in leg after MVC
To determine integrity of medial and lateral collateral ligament; also present tenderness along medial and lateral joint line
Dumping syndrome; small and frequent meals; no simple sugar
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
Elevated non seminomas

50. several knee pain after being tackled in football game
Dull scrotal pain relieved by recumbency; soft scrotal mass disappears in recumbent position
Amoxicillin-clavulanate
Force applied from lateral to medial direction; likely injury to medial colaterl ligament; positve valgus test (L for lateral force)
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

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USMLE Step3 Surgery

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